Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tension-type headache, cervicalgia
Treatment: Chiropractic services CPT (Current Procedural Terminology) code 99215-25 (Office or other outpatient visit for the evaluation and management (E/M) of an established patient)

The insurer denied coverage for chiropractic services CPT code 99215-25 (Office or other outpatient visit for the evaluation and management of an established patient).
The denial is upheld.

The patient has a history of tension type headaches. She underwent a re-evaluation for complaints of headache with pain, stiffness, and discomfort in the shoulders. She was diagnosed with tension-type headache, cervicalgia, and segmental and somatic dysfunction of the cervical region. The treatment plan was for ultrasound, myofascial release, heat, and stretching for increased range of motion, reduced spasm and pain, increased muscle strengthening and endurance, and improving functional capacity for activities of daily living. Treatment duration plan was 2 times per week for 4 weeks with re-evaluation to be done in 4 weeks.

The records outline various components of the evaluation that may have been performed.  Outcome Assessment Forms (OAF) were not included and not part of this E/M session.  The patient had been treated for the same condition with the most recent visit prior to the E/M session completed.  No significant exacerbation or change of complaint or new injury was listed in the records.  The notes did not include any OAF that would indicate a functional impairment due to a new condition or significant exacerbation of the same condition.  OAF is also important to validate rationale for an updated E/M session and chart improvement for possible revision of care plan.  

The exacerbation factors listed was repetitive movement, working, exercise.  These are typical daily activities that the patient has and will continue to experience during her life.  These are suggestive of mild flare ups and not significant injury or exacerbations that would occur daily.  The patient manages her condition daily and continues her occupation.  The records did not support that the patient was released prior, indicating that the visit would be regular follow up treatment of the same chronic condition.  No other supporting history or documentation was submitted to support this condition or previous treatment success.  Subluxations were listed for cervical (C)1-2 and C5-6.  The note is difficult to read but appears to note (L) levator scapula and another listing.  No indication for additional co-management or additional imaging was noted.  Medical decision making (MDM) appears to be straight forward and in line with a daily observation/evaluation of the patient to be included (bundled) with the CPT procedure (98940) also performed on that date.  

The Council on Chiropractic Guidelines and Practice Parameters Best Practice: The Chiropractic Clinical Compass (CCGPP) guidelines indicate, "Re-evaluation may be indicated more frequently in the event a patient reports a significant or unanticipated change in symptoms and/or there is a basis for determining the need for change in the treatment plan/goals." 
 
The records reviewed did not support rationale for an E/M service 99212-25 needing to be performed.  The records did not support a significant or unanticipated change in symptoms since the initial evaluation of this same chronic condition. 

The Mercy Conference Guidelines also state that the chart/progress notes "must be sufficiently complete to provide reasonable information requested by a subsequent health care provider, insurance company, and/or attorney. (e.g. progress notes, Subjective, Objective, Assessment and Plan (SOAP) notes)."  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for chiropractic services CPT code 99215-25 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making) provided is upheld. Medical necessity is not substantiated.