Manipulation Services

Policy ID: Y-9-040

Section: Therapy

Effective Date: April 01, 2019

Revised Date: November 13, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: November 15, 2023

Applies To: Commercial Only

Description

Manipulation and chiropractic manipulation, commonly referred to as spinal and extraspinal adjustment, manual adjustment, vertebral adjustment, or spinal manipulative therapy (SMT), is the treatment of the articulations of the spine and musculoskeletal structures, including the extremities, for the purpose of relieving discomfort resulting from impingement of associated nerves or other structures (e.g., joints, tissues, muscles).

Performance of these services requires the specialized knowledge, clinical judgement and skills of a qualified physical medicine provider.

Spinal manipulation by manual or mechanical means may be used to correct a structural imbalance or subluxation related to distortion or misalignment of the vertebral column.

Extraspinal manipulation, also known as extraspinal manipulative therapy (EMT), is used to treat joint dysfunction outside of the vertebral column.

Criteria

Manipulation and chiropractic manipulation may be considered medically necessary when ALL of the following are met:

Therapy is provided for a neuromusculoskeletal condition; and
Therapy is provided for the initial treatment of an acute condition, reinjury, or aggravation of a chronic condition; and
Therapy is provided for the purpose of minimizing or eliminating impairments, functional limitations, or restrictions of the condition; and
Therapy is provided in accordance with an ongoing, written treatment plan, appropriate for the reported condition, and is expected to result in restoration of the individual's level of function which has been lost or reduced by the condition

- A treatment plan includes:
  - Osteopathic Manipulative Treatment (OMT); or
  - Chiropractic Manipulative Treatment (CMT); and
  - A maximum of four (4) modalities/procedures on any given date of service, per performing provider including:
    - Muscle and range of motion (ROM) testing; or
    - Physical tests and measurements; or
    - Therapetic exercises to develop strength, endurance, ROM and flexibility; or
    - Mechanical Traction; or
    - Neuromuscular reeducation; or
    - Therapeutic massage.

Manipulation and chiropractic manipulation provided exclusively for the convenience of the individual or provider, for relaxation, or for personal lifestyle enhancement are considered not medically necessary.

Manipulation and chiropractic manipulation provided for ALL of the following are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

Non-musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, etc.); and
Prevention/maintenance/custodial care; and
Internal organ disorders (e.g., gallbladder, spleen, intestinal, kidney, or lung disorders); and
Scoliosis correction; and
Manipulation of infants, less than or equal to 12 months, f or non-neuromusculoskeletal indications (e.g., infants with gastrointestinal disorders including constipation, excessive intestinal gas and gastroesophageal reflux disease).

Unattended massages that do not require the services of a professional provider are considered non-covered.

Quantity of services that exceeds the frequency guidelines listed on the policy are considered not medically necessary.

Procedure Codes

95851

95852

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97036

97110

97112

97113

97116

97124

97150

97530

97535

97542

97750

97760

97761

97763

98925

98926

98927

98928

98929

98940

98941

98942

98943

G0283

S8950

Habilitative therapy services may be considered medically necessary when the following criteria are met.

Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and
Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies

*Spinal manipulation is not considered a habilitative service.

Habilitative therapy services not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

95851

95852

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97036

97110

97112

97113

97116

97124

97150

97530

97535

97542

97750

97760

97761

97763

98925

98926

98927

98928

98929

98940

98941

98942

98943

G0283

S8950

Maintenance Services

Maintenance Services begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur.

A maintenance program consists of activities that preserve the individual's present level of function and prevent regression of that function. These services would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.

Procedure Code

S8990

Vertebral axial decompression (examples include, but are not limited to, VAX-D, DRX9000, Spine Med, Tru-Trac Traction Table) is considered investigational experimental/investigational and, therefore, non- covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

S9090

For Evaluation and Management (E/M) Services criteria. Please see BCBSND Reimbursement Policy for Chiropractic Services

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 clarification to statement that manipulation of infants is E/I for non-neuromusculoskeletal conditions

Internal Medical Policy Committee 3-16-2020 Revision

Removed reimbursement language, and
Criteria rewritten for clarification

Internal Medical Policy Committee 1-19-2021 Coding update:

Removed procedure code 99201
Added procedure code 99417

Internal Medical Policy Committee 3-17-21 Coding update:

Added procedure codes 97799, 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943.

Internal Medical Policy Committee 3-23-2022 Annual Review, no changes in criteria

Internal Medical Policy Committee 7-21-2022 Revision with coding - Effective September 05, 2022

Removedprocedure codes 97035; 97039; 97139; 97140; and 97799.

Internal Medical Policy Committee 3-23-2023 Revision - Effective April 15, 2023

Removed procedure codes 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215 and 99417; and
Removed Evaluation and Management (E/M) Services section.
Added Statement to see reimbursement policy for E/M services information

Internal Medical Policy Committee 5-23-2023 Reviewed policy, no changes in criteria.

Internal Medical Policy Committee 11-15-2023 Revision with coding - Effective January 01, 2024

Changed HCPCS code from S8890 to S8990

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: Y-9-040

Section: Therapy

Effective Date: April 01, 2019

Revised Date: May 22, 2023

Revision Effective Date: April 15, 2023

Last Reviewed: May 23, 2023

Archived Date: December 31, 2023

Applies To: Commercial and Medicaid Expansion

Description

Performance of these services requires the specialized knowledge, clinical judgement and skills of a qualified physical medicine provider.

Spinal manipulation by manual or mechanical means may be used to correct a structural imbalance or subluxation related to distortion or misalignment of the vertebral column.

Extraspinal manipulation, also known as extraspinal manipulative therapy (EMT), is used to treat joint dysfunction outside of the vertebral column.

Criteria

Manipulation and chiropractic manipulation may be considered medically necessary when ALL of the following are met:

Therapy is provided for a neuromusculoskeletal condition; and
Therapy is provided for the initial treatment of an acute condition, reinjury, or aggravation of a chronic condition; and
Therapy is provided for the purpose of minimizing or eliminating impairments, functional limitations, or restrictions of the condition; and
Therapy is provided in accordance with an ongoing, written treatment plan, appropriate for the reported condition, and is expected to result in restoration of the individual's level of function which has been lost or reduced by the condition

- A treatment plan includes:
  - Osteopathic Manipulative Treatment (OMT); or
  - Chiropractic Manipulative Treatment (CMT); and
  - A maximum of four (4) modalities/procedures on any given date of service, per performing provider including:
    - Muscle and range of motion (ROM) testing; or
    - Physical tests and measurements; or
    - Therapetic exercises to develop strength, endurance, ROM and flexibility; or
    - Mechanical Traction; or
    - Neuromuscular reeducation; or
    - Therapeutic massage.

Non-musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, etc.); and
Prevention/maintenance/custodial care; and
Internal organ disorders (e.g., gallbladder, spleen, intestinal, kidney, or lung disorders); and
Scoliosis correction; and
Manipulation of infants, less than or equal to 12 months, f or non-neuromusculoskeletal indications (e.g., infants with gastrointestinal disorders including constipation, excessive intestinal gas and gastroesophageal reflux disease).

Unattended massages that do not require the services of a professional provider are considered non-covered.

Quantity of services that exceeds the frequency guidelines listed on the policy are considered not medically necessary.

Procedure Codes

95851

95852

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97036

97110

97112

97113

97116

97124

97150

97530

97535

97542

97750

97760

97761

97763

98925

98926

98927

98928

98929

98940

98941

98942

98943

G0283

S8950

Habilitative therapy services may be considered medically necessary when the following criteria are met.

Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and
Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies

*Spinal manipulation is not considered a habilitative service.

Habilitative therapy services not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

95851

95852

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97036

97110

97112

97113

97116

97124

97150

97530

97535

97542

97750

97760

97761

97763

98925

98926

98927

98928

98929

98940

98941

98942

98943

G0283

S8950

Maintenance Services

Maintenance Services begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur.

Procedure Codes

S8890

Procedure Codes

S9090

For Evaluation and Management (E/M) Services criteria. Please see BCBSND Reimbursement Policy for Chiropractic Services

Diagnosis Codes

Not applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 clarification to statement that manipulation of infants is E/I for non-neuromusculoskeletal conditions

Internal Medical Policy Committee 3-16-2020 Revision

Removed reimbursement language, and
Criteria rewritten for clarification

Internal Medical Policy Committee 1-19-2021 Coding update:

Removed procedure code 99201
Added procedure code 99417

Internal Medical Policy Committee 3-17-21 Coding update:

Added procedure codes 97799, 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943.

Internal Medical Policy Committee 3-23-2022 Annual Review, no changes in criteria

Internal Medical Policy Committee 7-21-2022 Revision with coding - Effective September 05, 2022

Removedprocedure codes 97035; 97039; 97139; 97140; and 97799.

Internal Medical Policy Committee 3-23-2023 Revision - Effective April 15, 2023

Removed procedure codes 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215 and 99417; and
Removed Evaluation and Management (E/M) Services section.
Added Statement to see reimbursement policy for E/M services information

Internal Medical Policy Committee 5-23-2023 Reviewed policy, no changes in criteria.

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