If you follow the recommendations in part 1 [August issue] adequately, but your care is still denied by the reviewing organization or IME, you should prepare an appeal.
To win, you must clearly, logically and scientifically support the care you recommended to your patient. Following the published Clinical Compass guidelines is helpful in developing an appeal. I recommend you consider the following appeal outline.
A Sample Appeal Outline: What to Include
Introduction: Include the following or similar statement: "Please allow this correspondence to serve as an appeal to your denial. I will first address the specific facts of this case, and then address each point with which I disagree regarding your and/or your IME/file reviewer/consultant's recommendation to deny medically necessary care.
"Your denial stated the following: [specifically list the exact wording of the denial]. I wholeheartedly disagree with the rationale for this denial given the facts identified below. Please consider the following case facts."
Part I: Case Facts
History: [Briefly summarize the history, including the mechanism of injury.]
Physical Examination: [Briefly summarize the initial and subsequent examination findings, and be sure to qualify and quantify the individual tests. Ex.: "Kemp's test was positive with pain rated at 6/10, described as a dull ache to a sharp pain, extending from the left lower back into the left mid-gluteal region."]
Diagnostic History/Interpretation: [Briefly summarize the diagnostic test findings if present.]
Clinical Impression: [Briefly list the allowed diagnosis. As a practical matter, do not use subluxation or anything other than the allowed condition-specific diagnosis.]
Treatment Plan/Recommendations: [Briefly describe how you treated the patient, placing special emphasis on the transition from passive to active care, and including home care recommendations and exercise. Be sure to include referral to any other medical physicians, and describe the rational basis for any diagnostic tests you ordered.]
Functional Limitations [WC/PI]: [Briefly describe the challenges with home and work activities faced by the injured worker as a result of the pain associated with their work/PI injury.]
Complicating factors: [Itemize/list all complicating factors in the case.]
Goals of Care: (Short- and long-term goals) [WC/PI]: [Briefly identify how your care improved the patient. Ex.: "Patient presented at 8/10 on VAS, and within 12 visits reduced to 5/10, and within 24 visits reduced to just 2/10, demonstrating favorable and successful response to care at my office." You can do the same for the OAT-Roland Morris, Vernon-Mior, etc.]
Barriers to Recovery: [WC/PI] [Briefly describe any barriers to recovery. Ex.: "Residual weakness, inability to achieve a complete recovery, physically straining job, and employer does not have any light-duty work."]
Apply Legal Standards: [Ex: In Ohio, for example, care must meet Miller Criteria (causation, medical necessity of care, and cost effectiveness.)] Be familiar with the laws in your state. State something to the effect of: "In summary, the documentation in this case clearly complies standards related to medical necessity" and then document it with the following:
- Causation: Treatment is related to the original injury. [Briefly describe why you feel the current pain is related to the original injury.]
- Medical necessity: "Treatment was medically necessary, as evidenced by the vast amount of documentation that was supplied in this case. The goals (control pain, reduce reliance on medication, keep the patient as functional as possible and help the patient function and able to complete common activities of daily living) of chronic pain management have been met." Note: If supportive/chronic care is a benefit in the system, be sure to remind the hearing officer/case manager.
- Cost effectiveness: "Treatment is vastly more cost effective than any treatment that exists for control of the patient's permanent condition. Just consider that daily treatment is only $66-$100 per visit, compared to the tens of thousands spent on prior medical care. However, previous medical care was not questioned by this consultant or MCO."
Causation Statements: [WC/PI] [Make causation statements in this section using "based upon a high degree of chiropractic certainty" language. Ex: "In my opinion, based upon a high degree of chiropractic certainty, this patient did suffer an injury as a result of a work accident"; "In my opinion, based upon a high degree of chiropractic certainty, the current pain experienced by the patient is related to that injury; or "In my opinion, based upon a high degree of chiropractic certainty, the proposed treatment program of xx per week for xx weeks is also related to the injury, as well as being medically necessary."]
Comments/Opinions: [Make any closing statements supporting the care of your patient, if necessary.]
Editor's Note: In part 3 of this article (scheduled for October), Dr. Farabaugh completes his sample appeal, outlining how to respond to negative IME / file reviewer comments.
Dr. Ronald J. Farabaugh, past chairman of the CCGPP, been in practice since 1982, and has published on chiropractic guidelines and case management. Recently, he was elected to the Council on Chiropractic Education (CCE) as a Councilor-Category 2, representing clinicians. In 2015, he was positioned as the National Physical Medicine Director for Advanced Medical Integration Group, LP. He is also the founder/owner of www.chiroltd.com, an evidence-based, patient-centered, practice-management company dedicated to assisting DCs establish a more evidence-based office and referral mindset.