Manipulation or chiropractic (therapeutic) 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.
Manipulation, chiropractic manipulation, and physical medicine services 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
Manipulation, chiropractic manipulation, and physical medicine services provided exclusively for the convenience of the individual or provider, for relaxation, or for personal lifestyle enhancement are considered not medically necessary.
Manipulation, chiropractic manipulation, and physical medicine services 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:
Habilitative therapy services are ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury. This includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.
*Spinal manipulation is not considered a habilitative service.
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 patient'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.
The following services are considered experimental/investigational and, therefore, non-covered. Scientific evidence does not support the use of these services. This is not an all-inclusive list:
Internal Medical Policy Committee 3-16-2020 Removed reimbursement language, criteria rewritten for clarification
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.