Dear Appeals Committee

[My HMO refused to cover chiropractic treatment, but I am appealing. I am posting a draft of my letter here, in part because a major reason I blog is to get the goofy out of my system, but also because the cites may be useful to someone else who is pregnant, in pain, and dealing with a similarly recalcitrant insurer.]

I am writing to appeal your denial of coverage for chiropractic care to treat an injury sustained on 11/9/08.  Your letter states that you cover chiropractic treatment involving manipulation of the spine when a significant improvement can be expected from this treatment. Your own guidelines, then, indicate clearly that I should be reimbursed for chiropractic care.

I was referred by Dr. Sarah Swipich (=She Who Is Persuaded I'll Catastrophically Hemorrhage) for chiropractic treatment to address symphysis pubis dysfunction (SPD, alternatively known as Serious Pain in the Down-theres). According to Jain, Eedarapalli, Jamjute, and Sawdy (2006), SPD is the result of spinopelvic instability (do note the "spino-") caused by pregnancy-related hormonal changes. Treatment primarily involves manipulation of the sacrum, which is, as you well know, part of the spine. (I refer you to a little-known verse of "Dem Bones": "the S-spine's connected to the... L-spine, L-spine's connected to the...T-spine.") Peer-reviewed research has described excellent efficacy for treatment of SPD via spinal manipulation, with 100% of treated patients in one study reporting improvement (Andrews & Pedersen, 2003). More specifically, 25% reported full recovery, 62.5% reported moderate recovery, and every patient -- every last one -- reported a decrease in pain. An article in the Journal of Osteopathic Medicine also recommends spinal manipulation as a safe and effective treatment for SPD (Cassidy & Jones, 2002).

Let me sum up. Etiology of the problem: spinopelvic, emphasis on the spinal. Treatment of the problem: spinal manipulation. Likelihood of improvement with appropriate treatment: extraordinarily high. Criteria met for coverage under my plan: 3/3.

If you elect, through doublethink or pure bureaucratic bullheadedness, to deny this appeal, I must insist that you recommend an alternative treatment modality that would be covered. (I presume you are not in the business of telling patients suffering from incapacitating pain that they should just suck it up.) In more than a week of resting, icing, and taking Tylenol I noticed very little change in the pain, though I noticed an alarming augmentation of the piles of dirty laundry awaiting my attention. Should I take narcotics at 8 months pregnant? Should I stay on the couch with my ice pack, awaiting a miraculous healing and perhaps the miraculous ministrations of the Laundry Fairy? Should I plan a C-section if I cannot stand to keep my knees more than eight inches apart? Surely you could not in good faith suggest one of those as an alternative.

After you denied coverage I paid out of pocket to see Dr. Susan Swioug (=She Who Is Owed Undying Gratitude), who informs me that I have sacroiliac dysfunction and lumbar subluxations. Her manipulations of my lower spine were followed by the first real improvement I had seen in this pain in more than a week. This was accomplished quickly, comfortably, and non-invasively, with none of the risks of, say, narcotics. I came home and did battle with the laundry. (It's still winning, though. I will require further treatment before I can entirely vanquish the armies of dirty socks marshaled during my spell of couchbound convalescence.)

I expect to be reimbursed promptly for my visits to Dr. Swioug, since spinal manipulation for treatment of spinal problems is a covered benefit. If you have an alternative point of view, I will read it with the keenest interest -- as will, I am certain, the good people in the state regulatory office. Please reply at your earliest convenience.

Yours optimistically,
CJ Most-Gladly

Andrews, S., & Pedersen, P. (2003). A study into the effectiveness of chiropractic treatment for pre and postpartum women with symphysis pubis dysfunction. European Journal of Chiropractice, 48, 77–95.

Cassidy, I.T., & Jones, C.G. (2002). A retrospective case report of symphysis pubis dysfunction in a pregnant woman. Journal of Osteopathic Medicine, 5(2), 83-86.

Jain, S., Eedarapalli, P., Jamjute, P., and Sawdy, R. (2006). Symphysis pubis dysfunction: a practical approach to management. The Obstetrician and Gynaecologist, 8(3), 153-158.

Comments

[Heather Cook]

You are goooood. :)

[Maria Wood]

Please please PLEASE keep us posted on their response!

[Karen]

snicker. They will lose this fight just on the fact that no one in the insurance business has a sense of humor!

[Lilian]

AWESOME!!!!! Thanks for sharing it, works cited and all! (that totally warms up my scholarly soul -- oh, oh how I miss your "scholarly" posts on homebirth and breastfeeding!).

[Renee]

You go, girl!

[Sarah in Ottawa]

Grr - it sucks that you have to go through this. I am glad to live in Canada and to have chiropractic coverage through both my work and my husband's without having to justify why.

I am very glad that you have sought chiropractic adjustments, though, and that they have helped you. My chiropractor is amazing and my adjustments have been invaluable since my pelvis unlocked at 13 weeks. And I thought I loved the chiropractor BEFORE pregnancy!