Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower back pain and Mid-back pain.
Treatment: the Chiropractic Manipulative Treatment (CMT); Spinal, 5 Regions, current procedural terminology (CPT) Code 98942, performed on the Dates of Service (DOS) in question. 

The insurer denied coverage for the CMT; Spinal, 5 Regions, CPT Code 98942, performed on the Dates of Service (DOS) in question.  The denial is upheld.

This is a female patient with a history of lower back pain and mid-back pain who presented to the chiropractor's office for treatments. She was treated with Chiropractic Manipulative Treatment (CMT); Spinal, 5 Regions, current procedural terminology (CPT) Code 98942. The CMT; Spinal, 5 Regions, CPT Code 98942, performed on the dates of service (DOS) in question were not considered medically necessary for this patient. Meaningful improvement of her clinical presentation and function were not established in the records reviewed and therefore not medically necessary.

The Council on Chiropractic Guidelines & Practice Parameters (CCGPP) states, "The purpose of this re-evaluation is to determine whether the patient has made clinical improvement. A determination of the necessity for additional treatment should be based on the response to the initial trial of care and the likelihood that additional gains can be achieved." The treatment records submitted for review did not include Outcome Assessment Forms (OAFs) to support functional improvement, plus the Visual Analog Scale (VAS) did not show any lasting, meaningful improvement in symptoms from treatments rendered or indicate any improvement of clinical objective findings that would clearly indicate the likelihood of meaningful improvement would be achieved with continuing chiropractic care. The records reviewed did not support lasting improvement or meaningful change from treatment and appears to resemble maintenance care for a chronic condition. The CCGPP guidelines state that to perform an examination, the provider must at least examine the area of chief complaint and examine all areas that will undergo a chiropractic adjustment and examine the areas to which the chief complaint refers pain. The Provider Chart Notes (PCN) reviewed do not support an appropriate, initial evaluation was performed during the course of care that would demonstrate medical necessity for treatment plus documentation of meaningful, lasting improvement was accomplished with treatment by way of appropriate follow up examinations. The PCN failed to document support that the patient had a significant health problem in the form of a neuromuscular condition other than some subjective findings that were not consistent throughout the complete treatment protocols. The PCN failed to support that the manipulative services rendered had a direct therapeutic relationship to the patient's condition and provided reasonable expectation of recovery or improvement of function.

CCGPP guidelines state that for a trial of care to be considered beneficial, it must be substantive, meaning that a definite improvement in the patient's functional capacity has occurred. The PCN did not support appropriate OAFs or successive objective measurements for improvement. The PCN did not support that the clinical condition displays meaningful and lasting improvement in response to therapy. Denial is appropriate. The records submitted for review did not support meaningful and lasting improvement with chiropractic care, failed to utilize OAFs to document functional improvement and failed to identify functional improvement. 

 The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient. The records supported that the patient did not achieve any meaningful improvement with treatment that is ongoing.

The carrier's denial of coverage for the CMT; Spinal, 5 Regions, CPT Code 98942, performed on the DOS in question is upheld. The medical necessity is not substantiated.