Chiropractic Care denials in California external review
In the California DMHC record, independent physician reviewers decided 158 published external-review cases involving chiropractic care and overturned the plan’s denial in 31.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By denial reason
| Denial reason | Decisions | Overturned |
|---|---|---|
| medical necessity | 134 | 35.8% |
| experimental / investigational | 21 | 9.5% |
Within this category
| Subcategory | Decisions | Overturned |
|---|---|---|
| Other | 68 | 25% |
| Pain Management | 37 | 35.1% |
| Spinal Adjustment | 22 | 31.8% |
| Joint Manipulation | 19 | 42.1% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 134 | 35.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 21 | 9.5% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 3 | 0% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with low back pain, cervical radiculopathy, cervical disc degeneration, dorsopathies, muscle spasm, postural kyphosis of the cervical and thoracic spine, and segmental and somatic dysfunction of the cervical, lumbar, and sacral regions. The patient reported her cervical, upper thoracic, and lumbar pain had improved with chiropractic treatment but worsened with activities of daily living and stress. She rated her pain as five out of 10. Physical examination findings included antalgic gait, a head forward posture, and a high left shoulder and right hip. Muscle spasm was also noted. The records noted approximately 15 chiropractic sessions from 1/1/20 through 2/12/20. The patient has requested authorization and coverage for 30 to 60 chiropractic treatments over the next year.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for chiropractic services. Researchers conducted a randomized controlled trial to establish the short-term effectiveness of chiropractic therapy for spinal pain compared with a sham intervention. These researchers concluded that short term chiropractic treatment was superior to sham treatment for spinal pain. Another team of researchers conducted a randomized clinical trial to compare the effectiveness of high velocity and low amplitude (HVLA) manipulation vs. posteroanterior mobilization (PA mob) vs. sustain appophyseal natural glide (SNAG) in the management of patients with neck pain. These researchers concluded that HVLA and PA mobility groups relieved pain at rest more than SNAG in patients with neck pain.
Where the denial was upheld
Physician 1: The patient is a 21-year-old male with a lumbar disc herniation at the L2-3 level. His condition is described as stable with lower back, buttock, and right leg pain. He reports his pain as moderate and tolerable. He has not been able to return to his usual activity level and corrective surgery consisting of decompressive laminotomy and discectomy was recommended. Lumbar traction was discussed and the patient requested a referral. He consulted with a chiropractic office and VAX-D treatments ensued. Approximately 30 sessions were provided with apparent positive results.
Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for physical therapy services utilizing neuro-elongation therapy, Schroth method, and scientific exercises approach to scoliosis (SEAS) based physiotherapy exercises, five days per week every three months. Idiopathic scoliosis typically presents in adolescence and when manifested from ages four to 10, it is called juvenile idiopathic scoliosis. Juvenile idiopathic scoliosis has been observed to have a greater curve progression in comparison to adolescent onset idiopathic scoliosis, particularly given the prolonged time span between deformity onset and skeletal maturity. Various treatment modalities are available including braces, manual therapy, chiropractic, shoe inserts, and physical therapy.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this category of care generally, not any individual case.
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 care, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY