Diagnosis: Generalized musculoskeletal pain.

Treatment: Chiropractic services (codes 98941, 97124 and S8948).

The insurer denied coverage for chiropractic services (codes 98941, 97124 and S8948).

The denial is upheld.

This female patient had complaints of generalized musculoskeletal pain, including but not limited to head, neck, shoulders, arms, back, buttocks and legs. The patient's treatment included chiropractic treatment. Under review is the medical necessity for chiropractic services (codes 98941, 97124 and S8948).

The chiropractic treatment notes provide insufficient objective clinical information to support the medical necessity for the date of service under review. The chiropractic notes over the several months of treatment (36 visits) are much the same. For example, the physical examination findings with reported "moderate to severe muscle spasms" were unchanged. Physical examination findings via manual muscle testing were also unchanged. The patient's pain ratings varied without consistent improvement. The provided treatment for reported generalized musculoskeletal pain, with the lack of significant quantitative functional improvement, is consistent with maintenance treatment. Therefore, the chiropractic treatment at issue is not considered medically necessary.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, coverage for chiropractic service (codes 98941, 97124 and S8948) was not medically necessary.

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

Based on the above, the medical necessity for the chiropractic service (codes 98941, 97124 and S8948) is not substantiated. The insurer's denial should be upheld.