Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back Pain

Treatment:  Chiropractic Services

The insurer denied the chiropractic services.  The denial was upheld.

This is a female patient that presented to a chiropractic office with complaints of dull achy stiffness and lower back pain rating it 5-6/10 in severity.  The patient indicated that the pain interferes with her activities of daily living (ADLs).  On exam it was reported that the patient had multiple trigger points in the lumbar paraspinals and decreased lumbar mobility point tenderness to lumbar vertebrae and sacroiliac joints as well as a short leg.  The patient was treated with chiropractic manipulative treatment (CMT), moist heat, and exercise.

According to the documentation submitted, the patient was a female who returned for chiropractic treatment to her chiropractor.  According to a letter the patient presented to the office with complaints of lower back pain and stiffness, multiple trigger points in the lumbar paraspinals and decreased lumbar mobility point tenderness to lumbar vertebrae and sacroiliac joints as well as a short leg.  According to a document the patient had spinal manipulation treatment.  

The provider listed that the patient's clinical condition during this treatment regimen was "unchanged", "slightly improved" and/or "slightly worse without any measured functional assessment.  The patient's objective findings included muscle hypertonicity and muscle tenderness with restricted movement, (without change).  The patient's treatment rendered was same or similar for all records submitted for those dates of services, which included a chiropractic manipulative treatment (CMT), moist heat, and exercise.  The patient's diagnosis was not listed in the progress notes.

The CCGPP guidelines indicate that "[w]hen 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 CCGPP guidelines also state 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.  In this case, the medical records did not support additional meaningful and measurable improvement with the patient's current clinical condition and the rationale for expectations of additional clinical improvement to be achieved with ongoing chiropractic treatment was not supported.  The patient's pain scales had minimal change, and the patient's functional improvement failed to be established.  The record suggested that ongoing chiropractic care would be considered as maintenance care and not medically necessary. 

According to the guidelines for Centers for Medicare & Medicaid Services (CMS) on the medical necessity for chiropractic care (CMS section 240), the "patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function."  In this case, the records submitted for review did not support chiropractic manipulative services providing a reasonable expectation of recovery or improvement of function.  The treatment on the dates of service in question supported maintenance care and would not be considered as medically necessary. 

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 services is upheld.  The medical necessity is not substantiated.