05-31-2017, 12:35 PM
(05-31-2017, 05:27 AM)1 Hurt nurse Wrote: Thanks! I tried to PM you my email address but I don't think it went through.
The only things I see on the treatment guidelines for lower back and neck injuries are acupuncture and opioids. Seems very bleak.
The treatments that are helping me are rolfing, pilates and chiropractic. They were specifically recommended by my QME. I can start seeing an acupuncturist if you think they will cover it. Do you think there is a way to get my current treatments covered? I am happy to copy and paste my last QME report if that would help.
I will check to see if I can get into my pm.
If you are looking only at the MTUS and chronic pain guidelines those can be very limiting. You can also use ODG and OCOEM 2nd edition and I have gone outside and used other treatment guidelines and peer reviews if the condition or the request does not fall under listed guidelines. Never limit yourself to guidelines, especially MTUS.
There is a cap in California for chiropractic treatment. If you have had 24 it will be extremely difficult to get more approved.
Acupuncture can be approved and also sometimes Pilates. There are caps to acupuncture. If you can do Pilates I highly suggest continuing if your doctor has recommended it and you can tolerate it. Pilates and yoga can be a way out of chronic pain, you need a strong will and be extremely careful to not reinjure yourself. Have you had regular physical therapy by a licensed physical therapist? Is your injury to neck and lower back? I ask this because I need to know the body part to look up appropriate guidelines for you.
I would be hesitant to paste your QME report on public site. Hopefully pm is working.
I want you to review this IMR denial for acupuncture. Make sure your doctor makes a request for the initial 3-6 sessions for example. If your doctor used the MTUS guidelines, he would have to state you are using it with rehabilitation exercise pilates and you either cannot tolerate or have reduced medication. This is if you used this guideline.
file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/3J7ZA45B/CM15-0027832.pdf
This is an IMR that approved request for continued acupuncture. You can see how the reviewer layed it out and explained why the request was warranted and quoted the guideline. Your doctor should be doing the same when he makes a request. You can also try to do it during an internal UR appeal or IMR, but easier when the doctor does it.
file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/UJ0Z50K2/CM13-0031267.pdf
Another example for low back for your review.
file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/4W4LO7LB/CM15-0023185.pdf
Whoever this IMR reviewer was, I like his ?
file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/Q8HP2EP2/CM14-0216393.pdf
This IMR reviewer approved acupuncture for lower back and cervical spine and used ODG guidelines. It is important you list both if you need acupuncture for both. In these reviews records are included. Your doctor may have to send relevant records unless he includes the relevant information in his report.
file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/3J7ZA45B/CM14-0176753.pdf
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.