Manipulation Services (Medicaid Expansion)

Policy ID: ME-Y-9-001-03

Effective Date: January 01, 2024

Revised Date: April 03, 2024

Revision Effective Date: April 01, 2024

Last Reviewed: April 03, 2024

Applies To: Medicaid Expansion 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.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Medicaid Expansion (ME) covers chiropractic spinal manipulation, limited new and established patient evaluation and management (E/M) services, and x-rays.

Chiropractic Spinal Manipulation Treatment services are limited to 20 per calendar year for Medicaid Expansion members. Chiropractic Manipulation Treatment (CMT) may be considered medically necessary when ALL of the following are met:

Treatment is provided for a neuromusculoskeletal condition; and
Treatment is provided for the initial treatment of an acute condition, reinjury, or aggravation of a chronic condition; and
Treatment is provided for the purpose of minimizing or eliminating impairments, functional limitations, or restrictions of the condition; and
Treatment 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:
  - 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
    - Therapeutic 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.

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

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

Habilitative Therapy

Habilitative therapy services are 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

98940

98941

98942

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

Evaluation and Management (E/M) Services

New Patient Evaluation and Management (E/M) services (99202 or 99203) are covered in addition to the CMT (98940-98942) only when the patient has not received any professional (face-to-face) services from the chiropractor, or another chiropractor of the same group practice, within the past three (3) years.

Established E/M service (99211-99213) are limited to five (5) services per calendar year.

Any services outside of those listed below are not covered when rendered by a Chiropractor for Medicaid Expansion members.

Procedure Codes

72020

72040

72050

72052

72070

72072

72074

72080

72100

72110

72114

72120

72220

99202

99203

99211

99212

99213

98940

98941

98942

EMT is not a covered benefit under Medicare Expansion (ME)

Noncovered

98943

The following X-rays may not exceed two (2) per spinal region per year and are limited to radiological examinations of the full spine, the cervical, thoracic, lumbar, and lumbosacral areas of the spine.

72020 Radiologic examination, spine, single view, specify level

72040 Radiologic examination, spine, cervical; two (2) or three (3) views

72050 Radiologic examination, spine, cervical; four (4) or five (5) views

72052 Radiologic examination, spine, cervical; six (6) or more views

72070 Radiologic examination, spine, thoracic, two (2) views

72072 Radiologic examination, spine, thoracic, three (3) views

72074 Radiologic examination, spine, thoracic, minimum of four (4) views

72080 Radiologic examination, spine, thoracolumbar, two (2) views

72100 Radiologic examination, spine, lumbosacral; two (2) or three (3) views

72110 Radiologic examination, spine, lumbosacral; minimum of four (4) views

72114 Radiologic examination, spine, lumbosacral; complete, incl bending views, min six (6) views

72120 Radiologic examination, spine, lumbosacral; bending views only, two (2) or three (3) views

72220 Radiologic examination, sacrum, and coccyx, minimum of two (2) views

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

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

Adopted Medicaid Expansion specific policy.

Internal Medical Review - 4-3-2024 - Revision - Effective April 01, 2024

Updated criteria; and
Removed 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; G0283; S8950; and
Added procedure codes 99202; 99203; 99211; 99212; and 99213.

Links

Not Applicable

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: ME-Y-9-001-01

Effective Date: January 01, 2024

Last Reviewed: November 15, 2023

Archived Date: March 31, 2024

Applies To: Medicaid Expansion Only

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
    - Therapeutic 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

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 Code

S8990

Procedure Code

S9090

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

The following X-rays may not exceed two (2) per year and are limited to radiological examinations of the full spine, the cervical, thoracic, lumbar, and lumbosacral areas of the spine.