Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Radiculopathy, lumbar disc herniation, and lumbago with sciatica

Treatment: CPT code 98941, CPT code 97112, CPT code 97140, and CPT code 97110

The insurer denied coverage for: CPT code 98941, CPT code 97112, CPT code 97140, and CPT code 97110. The denial is upheld.

This patient is female with a history of radiculopathy, lumbar disc herniation, and lumbago with sciatica. The patient had obtained a magnetic resonance imaging (MRI) of the lumbar spine for low back pain, which revealed stable degenerative changes with multi-level annular bulges at L2 through L5/Sacrum, with superimposed disc herniation at L2-3 and L4-5, and mild to moderate central canal stenosis at L2-3 and mild central canal stenosis at L3-4.  The patient received treatment. Documentation revealed that the patient reported lower back stiffness and pain with radiation.  Documented procedure codes (CPT) for this visit were 98940 and 97110. Per the visit note, a Home Exercise Program was recommended.

During her treatment, the patient reported chronic back pain and stiffness with occasional radiation of pain. The visit note on specified date did not indicate that any treatment was given to the patient.  Other visit notes indicated that the patient was treated with a combination of CMT 98940 or 98941 (chiropractic manipulative treatment), 97110 (therapeutic exercises) and/or 97140 (manual therapy).  There were multiple DOS where it was documented that the patient was not consistently doing her home exercise program (HEP) and subsequently reported an increase in discomfort. The patient reported significant improvement when she was compliant with performing her HEP.

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) guidelines indicates that "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 dates of service (DOS) in question did not show meaningful and measurable improvement with the current treatment protocols and suggested that the maximum therapeutic benefit (MTB) was achieved prior to these DOS. The treatment rendered on the DOS in question would be considered maintenance care and not medically necessary. 

The CCGPP guidelines indicate that 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." In this case, the patient's progress note did not support additional meaningful and measurable improvement with the current clinical condition and rationale for expectations of additional clinical improvement to be achieved with ongoing chiropractic treatment was not supported. The progress note also did not support a reasonable expectation of function with the treatment rendered clinically.  The treatment plan was an ongoing 1x/week which would suggest supportive care and not considered medically necessary.

The health plan acted reasonably with sound medical judgement, and in the best interest of the patient.

Based on the above, the medical necessity for chiropractic services: CPT code 98941, CPT code 97112 for date of service specified; CPT code 97140 for date of service specified; and CPT code 97110 for dates of service specified is not substantiated. The insurer's denial should be upheld.