Chiropractic denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for four chiropractic services a month. In a systematic review and meta-analysis of 47 randomized controlled trials on the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain, Rubinstein and colleagues reported that SMT produced similar effects to recommended therapies for chronic low back pain, and appeared better than non-recommended interventions for the improvement in function in the short term. Coulter and colleagues concluded that there is moderate quality evidence that both manipulation and mobilization appeared safe and were likely to reduce pain and improve function for patients with chronic low back pain, with manipulation appearing to produce a larger effect than mobilization. In this case, the patient has chronic low back pain.

A 25-year-old female has requested chiropractic services for treatment of her neck pain. Findings: The physician reviewer found that based upon the medical records provided, the requested chiropractic care is medically necessary for treatment of the patient’s neck pain. The patient’s symptoms, clinical exam findings and physical therapy notes demonstrate that she meets the criteria for chiropractic treatment, in accordance with the Cochrane Library and Mercy Guidelines for chiropractic treatment. The submitted records from the patient’s providers, document the following: muscle imbalance of the cervical spine and shoulder girdle, decreased functional mobility, and an altered physiological function of the spine. Chiropractors are neuromuscular specialists and have particular expertise in managing these issues.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for chiropractic services. Researchers report, “Physical examination findings indicating hip dysfunction are common in patients presenting with lower back pain.” In a randomized controlled trial, researchers concluded, “Spinal manipulation improves the results of physiotherapy over a period of three months for patients with subacute or chronic lumbar radiculopathy.” In this case, the patient reports a dull tightness of the left hip that is not described as painful. The records do not document pain in the lower back.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services (twice a week for 5 months and once a week thereafter) and chiropractic services (twice a week for 5 months and once a week thereafter).According to medical literature, a full course of acupuncture is considered six treatments. Additionally, a study by researchers found that a positive, clinically significant number of chiropractic visits is nine to twelve visits. In this case, the patient has had both acupuncture and chiropractic sessions approved (at least 12 sessions of each type). The submitted documentation shows that the patient has had prior chiropractic treatment, with no change in symptoms. Additionally, there were no quantifiable improvements noted after past acupuncture treatments.

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 Chiropractic, then check the rights and deadlines that apply to your plan.