Joint Manipulation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested continued chiropractic services.The patient has requested authorization and coverage for a chiropractic service for segmental and somatic dysfunction of the cervical region, tension type headaches, and segmental and somatic dysfunction of the thoracic region. On review of the records, the requested chiropractic services are medically necessary for the treatment of the patient’s condition. The records establish that the patient underwent chiropractic care for segmental and somatic dysfunction of the cervical region, tension type headaches, and segmental and somatic dysfunction of the thoracic region.

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.

Where the denial was upheld

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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued chiropractic care. On review of the current medical records, the requested continuation of chiropractic care is not supported as medically necessary for the treatment of this patient’s cervical and lumbar spine pain. The Clinical Practice Guidelines for Chiropractors in the United States, support that there is a lack of documentation to support ongoing chiropractic services. The records do not establish that the patient has experienced functional improvement with chiropractic services. Overall, the provider did not report that the patient has made clinically significant progress under the initial treatment program based on reliable and valid outcome tools or updated subjective and objective examination findings.

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