A review of the records reveals the member to be an adult male with a birth date of 10/04/1961. The member has a diagnosis of low back pain. The member’s treating provider, Ben Altmann, DC recommended the member continue chiropractic visits.
The carrier has denied coverage of continue chiropractic visits as not medically necessary. There is a letter from the carrier to the member dated 12/18/2015, which states in part:
“The committee upheld the denial based on the Definition of Maintenance Care and Medically Necessary, parts 1, 2, 4 and 5. Exclusion 8 also applies. The Section, COVERED EXPENSES shows the Maintenance Care exclusion. Based on further review, the services beginning on 08/11/2015 would be considered maintenance care as …show more content…
The specific definition of ‘Maintenance Care’ in the plan document page 18 is listed below:
Maintenance Care: healthcare services provided to a patient after the acute phase of an illness or injury has passed and maximum therapeutic benefit has occurred. Such care promotes optimal function in the absence of significant symptoms.
Maintenance Care is further referenced in this paragraph on page 26:
Benefits are not payable for maintenance care, custodial care, supportive care, or any health care service to which an exclusion applies. Please see section “GENERAL EXCLUSIONS”
Maintenance care is not references further in either GENERAL EXCLUSIONS or any other exclusions listed in the plan document.
You will note that there is no association of ‘Maintenance Care’ with chiropractic services in the Plan
Document, and no clear delineation of the time period that must pass before treatment becomes
‘Maintenance Care’. Nor is there any mention of any specific limitation on Chiropractic Services, or any clause or statement that clarifies how treatment of chronic illnesses might differ from ‘Maintenance
The carrier has denied coverage of continue chiropractic visits as not medically necessary. There is a letter from the carrier to the member dated 12/18/2015, which states in part:
“The committee upheld the denial based on the Definition of Maintenance Care and Medically Necessary, parts 1, 2, 4 and 5. Exclusion 8 also applies. The Section, COVERED EXPENSES shows the Maintenance Care exclusion. Based on further review, the services beginning on 08/11/2015 would be considered maintenance care as …show more content…
The specific definition of ‘Maintenance Care’ in the plan document page 18 is listed below:
Maintenance Care: healthcare services provided to a patient after the acute phase of an illness or injury has passed and maximum therapeutic benefit has occurred. Such care promotes optimal function in the absence of significant symptoms.
Maintenance Care is further referenced in this paragraph on page 26:
Benefits are not payable for maintenance care, custodial care, supportive care, or any health care service to which an exclusion applies. Please see section “GENERAL EXCLUSIONS”
Maintenance care is not references further in either GENERAL EXCLUSIONS or any other exclusions listed in the plan document.
You will note that there is no association of ‘Maintenance Care’ with chiropractic services in the Plan
Document, and no clear delineation of the time period that must pass before treatment becomes
‘Maintenance Care’. Nor is there any mention of any specific limitation on Chiropractic Services, or any clause or statement that clarifies how treatment of chronic illnesses might differ from ‘Maintenance