The New York Chiropractic Counsel and Donna Restivo, D.C., have retained the law firm of Pomerantz Haudek Block Grossman & Gross LLP to bring a class action against Aetna, Inc. for improper reductions in health care payments for chiropractors who are not part of Aetna's network of providers (known as out-of-network or "ONET" providers). 

The case focuses on Aetna's decisions in 2006 and 2007 to change its policy with regard to a number of chiropractic services and declare them to be not covered under its health care plans pursuant to their "experimental and investigational" exclusion.  In particular, Aetna claims that the following chiropractic services are no longer covered because they purportedly have not been demonstrated to be safe and effective:  Surface Scanning Electromyography ("SEMG") (CPT 95999); Mechanical Traction (CPT 97012); and Aqua Massage (Dry Hydrotherapy) (billed under Code 97022). 

In the complaint that is being prepared, the plaintiffs will allege for each of these practices that they are standard and common services which are generally accepted in the chiropractic community, such that ONET chiropractors such as Dr. Restivo are entitled to provide such services and to be paid appropriate benefits under Aetna's plans.  Plaintiffs believe that they have substantial evidence in support of their position.  With regard to SEMG, for example, a Florida court has explicitly found that it is a common and acceptable chiropractic service.  See Dep't of Health v. Merritt, Case No. 1D05-729 (Flor. 1st Dist. Ct. App. Jan. 5, 2006), at 8, 9 (the ALJ's finding that SEMG testing "has significant medical value as a diagnostic tool with respect to the treatment of a patient suffering from injuries like those arising out of a motor vehicle accident . . . is supported by competent substantial evidence"; "competent substantial evidence supports this finding . . . that surface EMG has reached a level of general acceptance in the relevant provider community," including both chiropractors and medical doctors).

Similarly, in Introna v. Allstate Ins. Co., 850 F. Supp. 161 (E.D.N.Y. 1993), the court explicitly held that "intersegmental traction treatments," among other chiropractic services, are, "as a matter of law, `normal and customary procedures and treatments offered by chiropractors'" and "lie squarely within the range of normal and customary `treatments and modalities.'"

The use of Aqua Massage (dry hydrotherapy) is also entirely appropriate.  Not only have various studies confirmed its efficacy, but the State of Washington has also adopted regulations which specifically call for the Chiropractic Quality Assurance Commission ("CQAC") to "maintain a classified list of chiropractic procedures and instrumentation" that are deemed to be "approved" for treatments by chiropractors.  Pursuant to this list, the CQAC has affirmative "approved" the use of aqua-med hydrotherapy tables, as well as intersegmental traction tables and SEMG.

Full story