Acupuncture denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 40-year-old woman with a history of sudden onset of vertigo occurring 5/24/2003. She also had a history of migraine headaches, which do not appear to always coincide with the episodes of vertigo. The patient also has had complaints of neck and back pain, stress, and vision problems. There is a significant diagnosis of benign paroxysmal positional vertigo and also a later possible diagnosis of Meniere’s disease.At the time the patient sought treatment from an acupuncturist her symptoms were vertigo, dizziness, unbalanced headaches, poor concentration, fatigue, weakness, and ear ringing. In his letter/report of 11/20/03, the patient’s acupuncturist reports a favorable response to clinical treatment, as do his chart notes for the treatment dates. The only exception is on 11/10/03 when there was an increase in symptoms due to the onset of menses.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services two times a week for six to twelve weeks.Clinical Practice guidelines from the American College of Physicians state that for patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment. The guidelines include acupuncture among their specified nonpharmacologic treatments. Vickers and colleagues have also noted that acupuncture is effective for the treatment of chronic musculoskeletal pain. Peer reviewed literature recommends an initial trial of six acupuncture appointments in combination with a conditioning program of aerobic and strengthening exercises. Future acupuncture appointments should be tied to improvements in objective measures to justify an additional six sessions.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for acupuncture services eight times a month, two times per week. According to medical literature, acupuncture is an effective treatment for patients with chronic musculoskeletal pain. In a review of the role of acupuncture in the management of lower back pain (LBP), migraines, fibromyalgia, neck pain, and abdominal pain, the authors concluded that “Based on the most recent evidence, migraine and fibromyalgia are two conditions with the most favorable outcomes after acupuncture.” Researchers reported that acupuncture with transcutaneous electrical nerve stimulation (TENS) was the protocol with the highest improvement in pain and quality of life for patients with LBP.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services.The available records support a history of bilateral shoulder pain and left elbow pain. The provider is recommending acupuncture treatment with electrical stimulation weekly for six weeks, with cupping and acupressure as needed. Medical studies show that acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Acupuncture, then check the rights and deadlines that apply to your plan.