ICA Calls for the Immediate Withdrawal of Blue Cross Blue Shield of Illinois’ “Choose Wisely” X-Ray Limitations
Written by Editor   
Thursday, August 23, 2018 04:48 PM

The International Chiropractors Association (ICA) has called for Blue Cross Blue Shield (BCBS) of Illinois to withdraw a portion of its coverage standards derived from the "choose wisely" guidelines.

The coverage standards listed under Diagnostic Imaging Services state that "The purpose of diagnostic imaging is to gain diagnostic information regarding the patient in terms of diagnosis, prognosis, and therapy planning. Required standards for each imaging study must meet the following four standards:

1. The study must be obtained based on clinical need;
2. The study must be of sufficient diagnostic quality;
3. There must be documented interpretation of the study to reach a diagnostic 
conclusion; and

4. The information from the study must be correlated with patient management.

The selection of patients for radiographic examination is based on the following guidelines:

1. The need for radiographic examination is based on history and physical examination findings;
2. The potential diagnostic benefits of the radiographic examination is judged to outweigh the risks of ionizing radiation;
3. Radiography is used to help the practitioner diagnosis pathology, identify contraindications to chiropractic care, identify bone and joint morphology, and acquire postural, kinematic, and biomechanical information;

4. Routine radiography of patients as a screening procedure is not appropriate practice except under public health guidelines."

The coverage standards also call for a "written record of the interpretive findings, the radiology report serves as an important part of the patient’s medical record and must contain:

  • Patient identification;
  • Location where studies were performed;
  • Study dates;
  • Types of studies;
  • Radiographic findings;
  • Diagnostic impressions; and
  • Signature with professional qualifications included. It may also include recommendations for follow-up studies; and comments for further patient evaluation.

"Providers are to bill and document appropriately for all services submitted. It is imperative that providers and their staff are aware of documentation requirements and payor medical policies for all services provided. Claims filed with documentation that do not meet the above listed requirements will be denied," BCBS states.

Writes the president of the ICA, George B. Curry, DC, FICA:

I am writing on behalf of the International Chiropractors Association (ICA) and our member doctors of chiropractic in Illinois, and, perhaps of greater importance, on behalf of the thousands of patients of all ages they serve each day, to call for the immediate withdrawal of your organization’s coverage standards (Chiropractic Services-Policy Number CPCP016) as they relate to chiropractic x-rays derived from the so-called “Choose Wisely” guidelines.

The ICA believes that these recommendations are out of line with the established standards of chiropractic practice, ignore the large body of clinical and outcomes data that demonstrates the utility, indeed clinical wisdom of such procedures, and clearly can and will, if followed unquestioningly, place patients at risk by delaying or denying diagnostic procedures that have been proven to best serve patients’ needs. In addition, the “Choose Wisely” recommendations have provoked a massive wave of concern, indeed outrage, on the part of scores of chiropractic organizations and, practitioners in the thousands, as simply an unwarranted, intrusive and harmful set of recommendations that can only reduce the safety and clinical effectiveness record of chiropractic. The Illinois Prairie State Chiropractic Association (IPSCA) is among the organizations taking a strong position opposing the Choose Wisely guidelines, stating:

“The Board of the IPSCA, on behalf of its membership, strongly disagrees with the recent American Chiropractic Association’s support of the American Board of Internal Medicine Foundation’s “Choosing Wisely” position on the use of radiographs. Many Chiropractic techniques (taught at accredited colleges) are dependent on Spinographs in order to determine the how and where to adjust the patient. X-rays also gives the practitioner the important information as to when a patient can’t be safely adjusted. Radiographs are often vital in work comp, personal injury and malpractice court cases. Without X-rays D.C.s can be hampered in the decision-making process critical to being a good Chiropractor.”

The chiropractic profession seems strongly united in seeing these guidelines as nothing less than an attempt to apply an inappropriate medical standard to the practice of chiropractic. ICA’s Clinical Guidelines Committee has carefully evaluated these so-called “Choose Wisely” recommendations and determined that while these recommendations may be applicable for the medical physician who might only proceed to prescribe or recommend pharmaceuticals, they are out of line for the practicing doctor of chiropractic since in the vast majority of cases, doctors of chiropractic apply a specific, directional force to the spine through the chiropractic adjustment process. Doctor of Chiropractic are responsible for assessing the spine to appropriately determine whether or not the patient has a vertebral subluxation and determining if, when and how a chiropractic adjustment may be applied. X-ray studies are a standard clinical tool providing necessary objective clinical evidence and are a critical component of numerous chiropractic techniques taught in all Council on Chiropractic Education (CCE) accredited programs.

Since its establishment in 1926, the International Chiropractors Association (ICA) has recognized that radiography is a scientifically proven, clinically valid and appropriate method to evaluate multiple aspects of human spinal anatomy, identify vertebral subluxations, altered spinal biomechanics, postural misalignments, pathology and in providing information and safeguards in rendering chiropractic care in clinical practice. All fifty of the US States have incorporated authority for Doctors of chiropractic to apply diagnostic x-ray procedures in their respective scopes of practice and all US chiropractic colleges teach x-ray procedures and analysis. Nationally, since 1972, the federal Medicare program has either required by statute or, recognized and accepted x-rays of the spine as a primary method of identifying and documenting a vertebral subluxation.

We would refer you to the ICA Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP) For Biomechanical Assessment of Spinal Subluxation in Chiropractic Clinical Practice, for a full and objective analysis of the research behind chiropractic x-ray utility. The ICA PCCRP document provides an extensive, rigorous review and appraisal of radiology protocols and their utilization in the context of chiropractic care settings, in conjunction with an exhaustive evaluation of the chiropractic and biomedical literature, including risk benefit ratios, measurement and patient positioning, and patient population applications. The PCCRP Guidelines are the only chiropractic x-ray guidelines ever accepted for inclusion in the National Guideline Clearinghouse (NGC), serving under the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The ICA Best Practices and Practice Guidelines can be viewed online here.

This evidence based PCCRP document includes an extensive list of clinical indications for taking an x-ray image of the patient such as suspected subluxation, history of trauma, including birth trauma, motor vehicle accidents, falls, postural and for the procedure by chiropractic profession to identify multiple clinical components including fractures, congenital, developmental, postural biomechanical and degenerative conditions, ruling out pathologies, assess the indications for appropriate options in performing a chiropractic spinal adjustment for both the acute and non-acute patient. The ICA’s Best Practices and Practice Guidelines also support comparison x-ray studies to effectively utilize certain techniques as it provides valuable information detailing the effects of the chiropractic adjustment and to assess and anticipate the patient’s response to care and future progress.

We hope that your organization will act swiftly to correct what we, and a host of other chiropractic organizations and educational institutions nationwide, see as an inappropriate policy not in the best interests of either practitioner or patient.

Thank you for your attention to these important concerns. We look forward to your response.

Sincerely yours,

George B. Curry, DC, FICA