Spinal Adjustment denials in California external review

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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for chiropractic services. Evans and colleagues conducted a multicenter randomized trial comparing 12 weeks of spinal manipulative therapy (SMT) combined with exercise therapy (ET) to ET alone. They concluded that for adolescents with chronic low back pain, spinal manipulation combined with exercise was more effective than exercise alone over a 1-year period. Eklund and colleagues conducted a randomized controlled trial to investigate the effectiveness of maintenance care on pain trajectories for patients with recurrent or persistent low back pain.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for treatment with a motorized decompression mechanical traction device.Lumbar disc herniation (LDH) is a clinical entity characterized by low back and leg pain caused by the compression of the lumbar spinal nerve root by a degenerative disc. The majority of patients respond to conservative treatment. Conservative treatment involves resting, drug therapy, physical therapy, exercise, manipulation, epidural injections, and bracing. One of the physical therapy modalities used in the treatment of LDH is traction. However, the authors of a study determined that medical literature suggests only short-term effectiveness of traction on low back pain with lumbar radiculopathy, regardless of the type employed.

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