Pain Management denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 53-year-old female with back pain and a diagnosis of scoliosis and segmental somatic spinal dysfunction with her cervical and lumbar spine. She requests additional chiropractic care of six treatments over three months. The treating record reveals x-ray findings of scoliosis at her thoracic and lumbar spine. A review of the submitted records does not reveal a developed and practiced home program of concurrent self-care. The Health Plan has denied further chiropractic care recommending referral to a physical therapist. The patient finds the chiropractic care to be helpful and has requested reconsideration of her authorization request. At issue is whether the requested chiropractic services are medically necessary for treatment of the patient’s medical condition.The patient’s diagnosis is one that is treatable by both physical therapy and chiropractic.

A 40-year-old female has requested coverage for past and future chiropractic treatment services for treatment of her intermittent neck and back pain. Findings: The physician reviewer found that current treatment guidelines state that the treating provider is expected to keep and maintain adequate case records clearly showing the patient care and clinical analysis from visit to visit. The following information is required within each subsequent visit: review of chief complaint; changes in the patient’s condition since the last visit; assessment of the patient since last visit; percentage of improvement, posture and gait analysis; pain scale; palliative and provocative assessment; range of motion; motor, sensory, and deep tendon reflexes (when warranted); systems review (especially if positive findings were documented with the last visit), including orthopedic and neurological evaluations…

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 46-year-old male has requested approval for past facet joint injections for treatment of his back pain. Findings: The physician reviewer found that on review of the patient’s records, the lumbar facet injections performed were not medically necessary for treatment of his medical condition. The patient’s history and physical examination from several office visits did not indicate whether the patient’s pain was derived from the facet joints. The imaging studies are significant for multi-level lumbar degenerative disc disease, facet hypertrophy, and neuroforaminal narrowing. It is difficult to determine the pathology of the patient’s chronic pain based on a physical examination without mention of findings on facet loading and imaging studies. In addition, the medical literature shows evidence for diagnostic lumbar facet injections in treating facet syndrome.

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