Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested continued chiropractic therapy, speech therapy and a dynamic upright magnetic resonance imaging (MRI) of the spine and brain for treatment of the enrollees shoulder pain, voice disorder and back pain.  Findings:  The physician reviewer found that the records do not include documentation of a significant focal neurological deficit or red flag symptoms or signs. Further, there is no documented a priori differential diagnosis specifying the suspected level(s) and side(s) of root involvement. As MRI is such a highly sensitive testing modality, non-specific findings are common, even in asymptomatic patients (Boden, et al and Jensen, et al). False positive or equivocal results are likely, and may result in anxiety or further, ultimately unnecessary and perhaps invasive testing, with no benefit to the patient. The test as presently ordered, is a screening test, which is not an appropriate use of this imaging modality. With regard to the requested standing brain MRI, there is no clear rationale provided for why this test is being requested. The patient had an alleged syncopal event following use of Flexeril. Initial work-up in the emergency room was negative and the records do not indicate that there have been any further events. Similar to the spine MRI, there is no documented a priori differential diagnosis or pre-test discussion about how the requested brain MRI would specifically alter or guide ongoing management of the patients condition. Thus, this screening test is also not an appropriate use of this imaging modality and was also appropriately denied. The patients request for continuation of chiropractic therapy is also without merit. In the medical literature, there is inadequate proof of sustained benefit of long-term chiropractic manipulation on health or functional outcomes for musculoskeletal pain, including for shoulder, neck or back pain (Koes, et al; Ernst, et al; and Gross, et al). Ernst and colleagues conducted a review of prior systematic reviews and concluded that, The notion that chiropractic or massage are effective interventions for pain control has not been demonstrated convincingly through rigorous clinical trials. Ultimately, this service is not of proven benefit according to the published peer-reviewed publications for this patients condition. The patient has been having chronic pain for many years and there is no clear demonstration of benefit following the treatment provided to date. Thus, the requested additional therapy is not expected to significantly improve the patients health, function or outcomes. Generally, non-pharmacological therapies involving active participation of patients, such as exercise and psychotherapy, appear more effective than passive measures such as chiropractic manipulation (Henningsen, et al). Finally, speech therapy referral for voice therapy is generally recommended for organic and non-organic voice disorders including persistent hoarse voice, particularly in the vocational setting, such as for singing (Feierabend and Shahram). Success of treatment depends on adherence to vocal hygiene principles and practice of the training exercises. In the present case, however, the patient has already undergone speech therapy and has already learned the basic principles for proper vocal hygiene as documented in the speech therapy notes. At the present time, it is essentially a matter of compliance with these principles. For these reasons, formal therapy would be maintenance in nature and is therefore not medically necessary.