Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines and Lower Back Pain

Treatment: Continued chiropractic services, codes 98941, CMT (chiropractic manipulative technique); spinal 3-4 regions, 98943, CMT extraspinal 1 or more regions, 97140, manual therapy techniques, one or more regions, each 15 minutes, and 97110, therapeutic procedure one or more areas, each 15 minutes

The insurer denied coverage for continued chiropractic services, codes 98941, CMT; spinal 3-4 regions, 98943, CMT extraspinal 1 or more regions, 97140, manual therapy techniques, one or more regions, each 15 minutes, and 97110, therapeutic procedure one or more areas, each 15 minutes

The denial is upheld

According to the documentation submitted, the patient had a history of migraines and lower back pain. She presented to th Neurology office for treatment. The patient noted that she tolerated the previous treatments well and has felt moderate improvement. She was satisfied with the care provided and the progress. A postural evaluation revealed a high right shoulder, cervical hyperlordosis, and lumbar hypolordosis. Short term goals (STG) included reducing pain and symptoms by 50% (percent). Long term goals (LTG) included improving passive and active range of motion, improving the ability to perform activities of daily living (ADL), returning to pre-injury status, relieving symptoms, improving nutrition, improving diet, increased fitness, strengthening, improved posture, increase in overall wellness, increase in overall health, decreased neurological symptoms, eliminating headaches, and functional neurological restoration. CMT adjustments were done. The chiropractor recommended returning for chiropractic treatments 1-2 times a week for the next 2-4 weeks.  

Magnetic resonance image (MRI) report displayed concentric disc bulging exerting pressure on the thecal sac, L (lumbar) 3-4 and L4-5 with mild disc bulging, L5-S (sacrum) 1, & possible bilateral spondylosis.  This MRI too old to the treatment dates.

The provider did not utilize appropriate documentation of functional improvement from treatment that would support meaningful improvement and necessity for ongoing care, covered by the health plan policy.  

The documentation submitted for review indicates the member had reached Maximum Therapeutic Benefit (MTB) prior to date of service.  Continuing care which does not demonstrate a reasonable level of therapeutic benefit is not medically necessary.  

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient.  The records supported that the patient did not achieve any meaningful improvement with treatment that is ongoing.  

The Chiropractic Manipulative Treatment (CMT); Spinal, 4 Regions, CPT Code 98941, performed was not considered medically necessary for this patient.  Meaningful improvement of her clinical presentation and function were not supported in the records reviewed and therefore not medically necessary, per the health plan policy.   

As the records submitted for review did not support meaningful and lasting improvement with chiropractic care, failed to document functional improvement and failed to identify functional improvement and the provider notes support that the clinical expectations have reached maximal medical improvement (MMI) and continued treatment is maintenance and not medically necessary at this time.

The insurer's denial of coverage for continued chiropractic services, codes 98941, CMT; spinal 3-4 regions, 98943, CMT extraspinal 1 or more regions, 97140, manual therapy techniques, one or more regions, each 15 minutes, and 97110, therapeutic procedure one or more areas, each 15 minutes is upheld. Medical Necessity is not substantiated.