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201912-123741

2020

Oxford

PPO

Orthopedic/ Musculoskeletal, Central Nervous System/ Neuromuscular Disorder

Chiropractic Services

Medical necessity

Upheld

Case Summary

Diagnosis: Mid and lower back pain -L4 and L5 region

Treatment: Chiropractic services.

The insurer denied coverage for chiropractic services. The denial upheld.

This patient is a female that sought treatment for ongoing mid and lower back pain. According to the UR report, this patient had been treated by the provider 60 times for musculoskeletal complaints related to the neck, upper back and lower back. She returned for updated complaints and diagnoses of pain in the thoracic spine. The provider treated her mid to lower back pain during this time and the patient was also advised to apply moist heat and follow through on a home exercise plan (HEP), at home.

The insurer denied coverage for the above DOS by determining that the services were not medically necessary. The records indicated that the patient returned to the office for updated diagnoses of M54.6 (Pain in thoracic spine), M99.02 (Segmental and somatic dysfunction of thoracic region) and S23.3XXA (Sprain of ligaments of thoracic spine, initial encounter). These were the consistent diagnoses in the claims data from the DOS in question. A review of the records submitted indicated that the office note for a date of service specified finds the patient had complaints related to the mid back, with a reported pain level of 9 on a scale of 10 (10 being the worst).

By DOS specified the complaint was reported to be at a pain level of 5-6 on a scale of 10. The records for a subsequent indicated the patient had presenting complaints of mid and low back pain after "sleeping wrong on a different bed." The given pain levels on this DOS were 7-8 and 8-10 on a scale of 10 for the mid back and low back respectively and by another DOS specified these reported pain levels had reduced to 5 and 3 on a scale of 10 for the mid back and low back respectively.

The Council on Chiropractic Guidelines & Practice Parameters (CCGPP) guidelines indicates, "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." The records submitted for review, reflecting the E/M service performed (99212-25) in question, did not support additional meaningful improvement in the patient's clinical condition to rationalize the need for ongoing chiropractic care. It appears that the patient had achieved a plateau in treatment and continuation of treatment would suggest physician dependency. Denial of the DOS in question appears to be appropriate.

According to the documentation presented for review, the health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The chiropractic services were not considered medically necessary for this patient.

The carrier's denial of coverage for the chiropractic services is upheld. The medical necessity is not substantiated.

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