| Milliman and Robertson is often used to deny
Chiropractic services, especially within the Worker's Compensation
system. However, it must be understood that M&R DOES NOT pertain to
chronic pain conditions. M&R guidelines are a set of optimal benchmarks
for treating common conditions for patients who have no complications.
Essentially they only relate to (1) non-complicated, (2) acute pain
patients, who are (3) off work.
There are several points within the updated Bulletin published by
M&R that are important to consider when faced with reviewer/nurse/claims
administrators who inappropriately reference M&R as a reason to deny
treatment for a complicated chronic work-related injury. The following
paragraphs are within the Bulletin.
"The Guidelines are written in a clear direct style because they are,
quite simply, guidelines for providing the right care, at the right
time, and in the right setting."
"They are not a prescription, a decision tree, or a set of rules for
the practice of medicine."
"In no situation are the Guidelines intended to be a substitute for
sound clinical judgment based on an individual patient's condition."
"Rather than rationing or reducing care, the goal of the Guidelines
is to provide a patient with the best care possible."
"When the M&R Guidelines are cited to the provider in the context
of a denial notice, that notice must contain reasons for denial, including
an easily understood summary of the applicable utilization management
decision criteria from the Guidelines used. It must also include how
the guideline cited is applied to the specific patient's condition.
When a payor adopts this approach, both the provider and the patient
are able to understand fully the rationale for the healthcare organizations
"Our licensing agreements require that all coverage decision communications
that reproduce or cite any part of the Guidelines must contain the
following statement: M&R Care Guidelines are not intended to be used
without the judgment of a qualified, healthcare professional taking
into account the individual circumstances of each patient's case."
"Anyone who uses the Guidelines as the sole basis for denying authorization
for treatment without proper consideration of the unique characteristics
of each patient or as the sole basis for denying payment for treatment
received is using our Guidelines inappropriately."