Manipulation Services

Section: Therapy
Effective Date: May 01, 2020
Revised Date: March 16, 2020
Last Reviewed: March 16, 2020

Description

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.

Criteria

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

  • A treatment plan includes:
    • Osteopathic Manipulative Treatment (OMT); or
    • Chiropractic Manipulative Treatment (CMT); and
    • A maximum of four (4) physical medicine modalities/procedures on any given date of service, per performing provider including:
      • Modalities; or
      • Therapeutic procedures; or
      • Muscle and range of motion (ROM) testing; or
      • Physical tests and measurements; or
      • Orthotic management and prosthetic management.

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:

  • Non-musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, etc.);
  • Prevention/maintenance/custodial care;
  • Internal organ disorders (e.g., gallbladder, spleen, intestinal, kidney, or lung disorders);
  • Scoliosis correction;
  • Manipulation of infants, less than or equal to 12 months.

Procedure Codes

95851 95852 97012 97014 97016 97018 97022
97024 97026 97028 97032 97033 97034 97035
97036 97039 97110 97112 97113 97116 97124
97139 97140 97150 97530 97535 97542 97750
97760 97761 97763 G0283 S8950    

 

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.

Procedure Codes

95851 95852 97012 97014 97016 97018 97022
97024 97026 97028 97032 97033 97034 97035
97036 97039 97110 97112 97113 97116 97124
97139 97140 97150 97530 97535 97542 97750
97760 97761 97763 G0283 S8950

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.

Procedure Codes

S8990


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:

  • Phonophoresis; and
  • Qi-Gong; and Cranial Manipulation/Cranio-sacral therapy; and
  • Vertebral Axial Decompression (examples include, but are not limited to, VAX-D, DRX9000, Spine Med, Tru-Trac Traction Table);

 

Procedure Codes

97035 97039 97139 97140 97799 S9090

 

Diagnosis Codes

NA

Professional Statements and Societal Positions Guidelines

NA

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Removed reimbursement language, criteria rewritten for clarification

Links

NA

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.