Chiropractic Manipulation denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for chiropractic services.According to Researches, scheduled interval ongoing management for secondary and tertiary prevention is recommended. The guidelines indicate continued chiropractic treatments when the patient demonstrates clinical improvements and should be discharged from active care with self-care instruction once the patient is stable. In this case, a review of the records confirmed that the patient underwent chiropractic manipulation involving three to four regions, which included the thoracic spine and cervical spine. The record reveals that there were no symptoms reported in the cervical and thoracic regions, and no physical examination in the cervical and thoracic regions took place.

A 41-year-old female enrollee has requested chiropractic treatment and/or physical therapy services for treatment of her rotator cuff syndrome and cervicalgia. Findings: The physician reviewer found that this patient suffers from symptoms of right shoulder pain secondary to bicipital tendonitis and rotator cuff impingement which have previously benefited from physical therapy treatment. Non-surgical treatment, based on the imaging results is appropriate for this patient’s condition at this time. This patient has a need for therapy which increases her shoulder range of motion and decreases her pain. As noted in an article by Camarinos and Marinko, manual physical therapy has been shown to be effective for painful shoulder conditions. Given the patient’s previous response to physical therapy, she is likely to benefit from a repeat course of therapy at this time.

Where the denial was upheld

A 39-year-old male enrollee has requested reimbursement for chiropractic services. The Health Plan has denied this request indicating the services at issue were not required on an urgent or emergent basis. Findings: The physician reviewer found that the patient was in a parked minivan which was struck by another vehicle. His body was not directly struck by that vehicle, but he did sustain injuries related to the rapid body movements caused by the impact. He had no focal head injury or loss of consciousness. He did not seek medical attention on the day of the collision for reasons related to his wife’s injuries and the need to care for his children, but he saw a chiropractor the next day with complaints of pain in his head, neck, upper and lower back, pelvis, and left elbow with numbness in his right hand. His pain was generally in the 7 out of 10 range.

A 36-year-old female enrollee has requested coverage for chiropractic/physical therapy treatments beyond the 38 treatments authorized and prospective coverage for continued chiropractic/physical therapy treatment (20 sessions). The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee’s moderate to severe right upper back and bilateral lower neck pain. Findings: The physician reviewer found that the patient has undergone extensive therapies since her 2009 injury, including various passive palliative interventions for pain relief. No significant, sustained benefit would be anticipated with further passive treatment such as chiropractic manipulation at this time.

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