Academy of Chiropractic’s
Doctors PI Program
From the Desk of:
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
"It's Not the IME or
Peer Reviewer, It's Me"
A $1,731.44 Claim Denied...That Didn't Have to Be
Let's start at the denial. Brian Smith DC, the peer review doctor, had a very easy time with this one. He wrote:
Based on the chiropractic documentation presented for my review, I am unable to recommend reimbursement for the lumbosacral orthosis dated October 4,2011 from Dr. Clueless, code L0631. The claimant in this particular case, Melissa Patient, was involved in a motor vehicle accident which happened in March 17,2011. The dates of treatment are approximately 5 months after the motor vehicle accident through 7 months after the motor vehicle accident occurred. There was a report from Dr. Clueless dated in April. The report from Dr. Clueless would only substantiate the need for treatment for approximately a month or 2. After that particular time, the claimant should be re-evaluated every 4 weeks to see if the claimant is responding well to conservative treatment. If the treatment plan should be changed and/or if the treatment program should be reduced or finished. In this particular case, there were no evaluations, reports or expanded SOPA notes from the date of service in August through October that would substantiate the need for treatment on those particular dates including spinal manipulation of 3 to 4 regions, therapeutic massage, and hot and/or cold packs. If that information does become available, I would be more than glad to review it and comment on those follow-up examinations. Also, the claimant on August 4,2011 was prescribed the lumbosacral orthosis. Lumbosacral orthosis will be prescribed in cases where there is evidence of spondylolisthesis, fracture, and/or instability of the lumbar spine. In this particular case, an MRI was provided which did not reveal spondylolisthesis, fracture, and/or instability. Therefore, there was no spondylolisthesis, fracture, and/or instability and the fact that the claimant was receiving chiropractic adjustments 3 to 4 regions at a frequency of 2 to 3 times a week. It certainly would be certain that the claimant had no fractures or instability and therefore the goals of therapy are to increase range of motion, not prohibited which this particular type of device would accomplish.
Immobilization has been used for thousands of years to treat injuries to the human body. Unfortunately, immobilization may lead to deleterious effects that may compromise treatment outcome, such as muscle fiber atrophy, decreased proprioception, and loss of cervical and lumbar range of motion (ROM). (McPartland JM, Brodeur RR, Hallgren RC. Chronic neck pain, standing balance and suboccipital muscle atrophy: A pilot study. J Manipulative Physiol Ther. 1997)
In this case, I agree with the peer review doctor. All this doctor had to have done was written an order and letter of necessity for the device in the initial evaluation and performed a re-evaluation every 4-6 weeks, stating how the device had been helping through follow-up testing. There has to be a rationale for care, making payment fit the profile for the carriers based upon necessity.
In addition, there should have been an evidenced-based macro certifying the need for the orthosis in this type of patient. The peer review doctor used a "pilot study" for his rationale to deny the claim...That is a very limited study. If the treating doctor utilized a full study, that would have negated the report cited and added to the prospect of getting paid.
Research is starting to show up more and more in IME and peer review denials as carriers are aiming at winning in court utilizing the Daubert standard (a legal standard for devices) to discredit you as an expert and preventing both you from getting paid and the plaintiff's lawyer from prevailing.
Would the carrier have paid if that was done? We will never know, but in a baseball metaphor, this doctor never even came up to the plate. What makes this worse is the doctor was the reason for the denial, not the carrier. There are rules of success and rules of failure. Learn the rules and play the game at the highest level because there is a reason why some excel and others blame everyone and everything for their failures.