Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Radiculopathy, cervical region, Subluxation complex (vertebral) of lumbar region.
Treatment: Chiropractic services- CPT codes: 98940, 97035, and 97110-GP
The insurer denied coverage for Chiropractic services- CPT codes: 98940, 97035, and 97110-GP. The denial is upheld. 

This is a female patient with diagnosis of M54.12- radiculopathy, cervical region and M99.13- subluxation complex (vertebral) of lumbar region. The patient presented to a chiropractor for evaluation. It was noted that she began having neck pain and stiffness as well as low back tenderness a few months prior. The patient's chiropractor is requesting approval for Chiropractic services that were provided: CPT codes: 98940- Chiropractic manipulative treatment (CMT); spinal, 1-2 regions, 97035- Application of a modality to 1 or more areas; ultrasound, each 15 minutes, and 97110-GP Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

The patient had a 5-week gap in treatment and her clinical complaints had not improved. The patient had 5 visits and the request was made for extended visits on her 6th visit. The chiropractor felt that since the patient had subjective complaints and subluxations and objective clinical findings, medical necessity would be established. He also notes that the patient has a condition that is chronic in nature due to her activities of daily living (computer work) and a stressful work environment. The records do not include successive objective measurements for improvement. The initial patient care notes (PCN) clearly outlined clinical findings that revealed subjective symptoms of pain in the neck upper back and lower back, with reduced range of motion (ROM), biomechanical changes, and palpable spasms/trigger points that would indicate necessity for chiropractic care. A treatment plan of 3 times per week for 2 weeks and then 2 times per week for 2 weeks was noted and appropriate for this condition. No Outcome Assessment forms (OAF) were utilized for a baseline of functional impairment and for a future recovery pattern to support medical necessity for ongoing treatment.

Treatment was rendered and no meaningful improvement was documented during these visits. The pain scale hovered between 4/10 and 6/10 during this time without lasting improvement or reduction of symptoms with care. ROM did not improve significantly during treatment, nor did palpable findings or objective examination findings on the last day of treatment. The patient did appear to be non-compliant with the care plan which may indicate a reduced need for treatment. A home exercise plan (HEP) was not identified in the records that would ween the patient off of physician dependency, considering the chronic nature of her clinical presentation.  

The Council on Chiropractic Guidelines and 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 re-evaluation did not document by way of OAFs and functional improvement, supporting clinical objective findings that would clearly indicate the likelihood of additional meaningful improvement would be achieved with continuing chiropractic care. Denial is appropriate.
The health plan acted reasonably and with sound medical judgement and in the best interest of the patient. The records supported that patient compliance was not accomplished, a HEP was not introduced and treatment appeared to be maintenance and physician dependent.  

Based on the above, the medical necessity for CPT codes: 98940, 97035, and 97110-GP provided for diagnosis code M54.12 is not substantiated. The insurer's denial is upheld.