Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical radiculopathy. 
Treatment: Chiropractic Services (97035 and 99212-25). 

The insurer denied the Chiropractic Services (97035 and 99212-25). 
The denial is upheld. 

The patient is a female. The records indicate that the patient presented to the office of the attending chiropractic provider (AP). The chiropractic records made available for review as well as the billing records indicate that the patient received chiropractic care under the administration of the provider on three dates of service. The records from earliest date of service indicate that the patient presented on that date with an exacerbation of symptoms to the neck. 

An examination/assessment was performed reviewing measurable deficits in cervical ranges of motion as well as positive orthopedic testing, normal reflexes and palpable changes. The records indicate that the patient presented on that date with an exacerbation. Similarly, the records indicate that the patient presented on the remaining submitted dates of service with additional exacerbations. The records reflect a course of care to include chiropractic manipulation, ultrasound and traction for the diagnosis of cervical radiculopathy. 

The records from the three dates of service/examinations do not reveal significant measurable objective changes in response to the ongoing course of care. Measurable ranges of motion were static to near static through the documented course of care. The records from the last date of service indicate that the patient presented with an exacerbation. The records reveal measurable deficits in cervical ranges of motion, positive orthopedic testing, negative reflexes and palpable changes. 

Per the records, the reason for the denial of the care under review was that the records do not document a significant change in symptomatology and therefore, did not support the administration of a separate examination. The stated reason for the denial of care related to ultrasound (97035) was due to the fact that the records did not support ongoing passive modalities. An appeal was requested with the opinion that the denied services were in fact "medically necessary and appropriately administered." 

No, the Chiropractic Services (97035 and 99212-25) are not medically necessary. 

It is understood that the services under review include ultrasound (97035) and an established patient examination (99212-25) for the last date of service.  The records made available for review include SOAP (subjective, objective, assessment, plan) notes from three chiropractic dates of service. The letter of appeal from the attending chiropractic provider (AP) states that medical necessity should be established for the services under review for the last date of service as the patient had not received care  due to a "hiatus" in care and that an examination was necessary to determine the patient's status and to determine the need for ongoing care. While it is consistent with standards of care and practice is within the chiropractic profession that timely periodic examinations are necessary and part of ongoing chiropractic management of a patient, the records do not support ongoing care as of the last date of service. Specifically, the records suggest that the patient was an established patient as of the first date of service. However, the records do not reveal the duration, frequency and intensity of care prior to the first date of service or response to care prior to the first date of service. Similarly, the records do not document an initial examination or the history of the patient's condition. More importantly, the records do not establish that the patient was continuing to measurably and objectively respond to the ongoing course of chiropractic care as of the last date of service. Specifically, while the chiropractic treatment records do reveal collections of measurable objective data in the form of cervical ranges of motion, the data does not indicate that the patient was continuing to significantly and measurably respond to the ongoing course of chiropractic care from an objective standpoint. Moreover, the records reveal a course of care that is infrequent and resembles a maintenance approach to treatment with no adherence to a standard active treatment plan and no perceivable endpoint to care. As such, as of the last date of service, the records do not support that the continuing course of care, to include the services under review for that date, would likely result in ongoing measurable objective relief. Therefore, medical necessity is not established for the course of care under review on the last date of service to include the established patient examination (99212-25) as well as ultrasound (97035). 

Yes, the records would support that the health plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

Consistent with the above discussions, the records do not establish reasonable expectations that the patient would continue to measurably and objectively and significantly respond to the ongoing course of chiropractic care as of the last date of service. As such, the records would not support the ongoing care under review as a reasonable component of the patient's ongoing treatment regime.