Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain, Mid-back pain, and Lower back pain.

Treatment: Chiropractic Manipulative Treatment (CMT); Spinal 1-2 Regions, Current Procedural Terminology (CPT) Code 98940, CMT; Extraspinal, 1 or More Regions, CPT Code 98943, Application or a Modality to 1 or More Areas; Traction, Mechanical, CPT Code 97012, and Manual Therapy Techniques, 1 or More Regions, Each 15 Minutes, CPT Code 97140-59

The insurer denied coverage for CMT; Spinal 1-2 Regions, CPT Code 98940, CMT; Extraspinal, 1 or More Regions, CPT Code 98943, Application or a Modality to 1 or More Areas; Traction, Mechanical, CPT Code 97012, and Manual Therapy Techniques, 1 or More Regions, Each 15 Minutes, CPT Code 97140-59

The denial is upheld. 

This is a female patient with a history of neck pain, mid-back pain, and lower back pain. The patient received chiropractic services on the dates of service under review. Based on the review of the medical record, the patient had undergone care for similar symptoms and an unchanging diagnosis for over 3 months.  Available office notes do not indicate that this patient's condition was improving despite ongoing care. There was no sustainable, measurable change in clinical status.  The services, provided on the dates of service under review, were not medically necessary for this patient.
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."  In this case, the treatment records indicate examination findings that did not include outcome assessment forms (OAFs) to support functional improvement, plus the visual analog scale (VAS) did not show any 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 CCGPP guidelines indicates, "When the patient's condition reaches a plateau, or no longer shows ongoing improvement from the therapy, a decision must be made on whether the patient will need to continue treatment."

The records reviewed did not support ongoing improvement or meaningful change from treatment and appears to resemble maintenance care for a chronic condition. The provider chart notes (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. According to the Centers for Medicare & Medicaid Services (CMS) - Maintenance therapy, "When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy."

The CCGPP guidelines indicate 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.  Examples of measurable outcomes and activities of daily living and employment include the following: pain scales, pain diagrams, outcome assessment forms. Denial is appropriate.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the Chiropractic Manipulative Treatment (CMT); Spinal 1-2 Regions, Current Procedural Terminology (CPT) Code 98940, CMT; Extraspinal, 1 or More Regions, CPT Code 98943, Application or a Modality to 1 or More Areas; Traction, Mechanical, CPT Code 97012, and Manual Therapy Techniques, 1 or More Regions, Each 15 Minutes, CPT Code 97140-59 should be upheld. The medical necessity is not substantiated.