MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Chiropractic Services

Number 8.03.501

Effective Date February 24, 2014

Revision Date(s) 02/10/14; 01/14/13; 05/08/12; 05/10/11; 05/11/10; 05/12/09; 06/10/08; 06/12/07; 05/09/06

Replaces N/A

Policy

NOTE: If benefits for chiropractic care are available, then the following criteria apply.

Chiropractic care and adjunct modalities may be considered medically necessary when ALL of the following criteria are met:

  • The patient has a neuromusculoskeletal condition/diagnosis that may improve or resolve with chiropractic treatment. (i.e. neuromusculoskeletal conditions include, but are not limited to, spondylosis, osteoarthritis, sprains and strains, headaches, degenerative conditions of the joints, repetitive motion injuries) AND
  • A patient-specific, goal-oriented treatment plan is documented (See Policy Guidelines) AND
  • The diagnostic procedures and treatment interventions are directly related to the patient’s symptoms.

Chiropractic care may be considered not medically necessary in asymptomatic patients or in patients without a documented neuromusculoskeletal symptom or complaint.

Continued chiropractic care may be considered not medically necessary in patients whose neuromusculoskeletal condition is neither regressing nor improving.

Chiropractic preventive or maintenance therapy may be considered not medically necessary. (See Policy Guidelines for definitions.)

Chiropractic care may be considered not medically necessary for correction of the curve in patients with idiopathic scoliosis.

Chiropractic care to solely restore spinal curves may be considered not medically necessary to treat spinal pain or to normalize spinal curves in asymptomatic patients.

Chiropractic care is considered investigational when it is provided for non-neuromusculoskeletal conditions because its effectiveness for these indications is unproven.

The following include, but are not limited to, procedures/techniques considered to be investigational:

  • Applied Spinal Biomechanical Engineering
  • BioEnergetic Synchronization Technique
  • Chiropractic Biophysics Technique
  • Coccygeal Meningeal Stress Fixation Technique
  • Cranial Manipulation
  • Directional Non-Force Technique
  • Dry Hydrotherapy
  • Gastron technique
  • Manipulation for Internal (non-neuromuscular) Disorders (Applied Kinesiology)
  • Manipulation Under Anesthesia
  • Moire Contourographic Analysis
  • Network Technique
  • Neural Organizational Technique
  • Neurocalometer/Nervoscope
  • Paraspinal Electromyography (EMG)/Surface Scanning EMG
  • Sacro-Occiptal Technique
  • Spinoscopy
  • Thermography
  • Thermomechanical massage (e.g., Spinalator, Hill Anatomotor, Chattanooga Ergo Wave)
  • Upledger Technique and Craniosacral Therapy
  • Wobble chair

Related Policies

1.01.517

Home Traction Devices: Cervical and Lumbar

2.01.35

Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain

2.01.56

Low-Level Laser Therapy

6.01.12

Thermography

6.01.46

Dynamic Spinal Visualization

7.01.551

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy

8.01.40

Manipulation Under Anesthesia

8.03.09

Vertebral Axial Decompression

8.03.502

Physical Medicine and Rehabilitation - Physical Therapy and Medical Massage Therapy

Policy Guidelines

The patient must have a significant health problem in the form of a neuromusculoskeletal condition that requires evaluation in order to determine when chiropractic treatment is appropriate or when it is not appropriate. Complaints of functional mechanical dysfunction related to a neuromusculoskeletal condition may include but are not limited to the following:

  • Cephalalgia
  • Limb symptoms (e.g. pain/numbness of arm(s), shoulder(s), hand(s),leg(s), foot/feet)
  • Musculoskeletal symptoms
  • Rib and rib/chest symptoms
  • Spinal joint symptoms

The symptoms in the list above, when clearly documented, are considered to be reasonable and necessary indications for therapeutic chiropractic manipulative therapy (CMT). The mere statement or diagnosis of “pain” is not sufficient to support medical necessity for CMT.

Coverage will be denied if continuation of chiropractic treatment is not expected to result in improvement of the patient’s condition. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvement, further manipulative treatment is considered maintenance therapy and is not covered.

Documentation Requirements

Documentation must be legible and include:

  • Initials of the provider of service and any staff/employees who provide services;
  • A key for any symbols or codes that are used by the provider and/or staff;
  • Brief notations, check boxes, and codes/symbols for procedures [e.g., neuromuscular re-education (NMR), myofascial release (MFR), hot packs (HP)] used in daily notes are acceptable only when the notations refer to the repeated application of a treatment modality which has been described in the current plan of care that meets the Physical Medicine and Rehabilitation - Physical Therapy and Medical Massage Therapy, medical policy (see Related Policies).

The clinical impression, diagnosis and treatment care plan documented for the initial and the follow-up visits must clearly support the medical necessity of the care and/or treatment provided. The initial treatment plan should not project care beyond a 30-45 day interval. (2)

Documentation of objective findings includes the following:

  • A physical examination specific to the patient’s reported complaint
  • Signs and symptoms of impairment or injury including cause and date of onset
  • Signs or symptoms of the patient’s inability to perform activities of daily living (ADLs)

The Chiropractic Plan of Treatment includes the following:

  • A patient-centered level of care that is appropriate for the symptoms, diagnosis and care of the condition
  • Objectively measurable short and long-term goals for specific clinical and/or functional improvements
  • Frequency and duration of visits for the treatment modalities to achieve the functional improvement goals
  • Anticipated date of discharge to self-care

Documentation of the patient’s progress at each follow-up visit includes the following:

  • The patient’s subjective complaint/symptom changes
  • Changes in objective physical findings of the patient’s current status
  • Measured clinical and/or functional improvement in the patient’s condition and meeting care plan goals
  • Updates to the initial treatment plan of care, as needed, with new goals that are appropriate to the patient’s condition with a defined timeframe to achieve the goals

Definition of Terms

Chiropractic Preventive Service is treatment for a patient who has no present pain or symptoms above their normal baseline but seeks to prevent pain/disability, promote health, and enhance quality of life. A preventive/maintenance program may include patient education, home exercises, and ergonomic postural modification. The appropriateness and effectiveness of CMT as a preventive or maintenance therapy has not been established by clinical research. Chiropractic preventive service is not a covered benefit.

Chiropractic Maintenance Therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. Maintenance therapy is not a covered benefit.

Examples of maintenance therapy include but are not limited to the following:

  • Ongoing repetitive treatment without a clearly defined clinical end-point and without evidence to support reasonable expectation of improvement;
  • Therapy to enhance strength and endurance;
  • A general exercise program to promote fitness;
  • Passive exercises to maintain range of motion and prevent deterioration of a chronic condition; and
  • Therapy that is provided after the patient has reached maximum rehabilitation potential or functional level has shown no significant improvement for two weeks.

Chiropractic Manipulation Treatment (CMT) or Spinal Manipulative Therapy (SMT)

A number of terms may be used to describe CMT/SMT:

  • Adjustment or manipulation is where there is an application of force using a high velocity-low amplitude thrust. The procedures may be performed either device/instrument-assisted or by manual therapy means only.
  • Adjustment or manipulation may apply to the spine, other joints and extremities and/or soft tissues with the goal to restore normal joint motion, improve functionality and relieve pain/nerve irritability secondary to disrupted biomechanics.
  • Correction may be used in lieu of the word treatment.
  • Mobilization is low velocity manipulation along with moving/stretching the muscles/joints to increase the range of motion in those symptomatic areas.

Subluxation is defined by Medicare (1) as a motion segment (of the spine), in which alignment, movement integrity and/or physiological function of the spine are altered although contact between joint surfaces remains intact. Subluxation usually falls into one of two categories:

  • Acute subluxation: is when the patient is being treated for a new injury, identified by history, physical exam and when clinically indicated, imaging studies.
  • Chronic subluxation: is when the condition is not expected to significantly improve or be resolved with further treatment (as in the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement.

Description

Chiropractic care is a branch of the healing arts that is based on the relationship between the structure and function of the human body as it relates to the spine. Chiropractic (therapeutic) manipulation may be referred to as spinal and extra-spinal adjustment, manual adjustment, vertebral adjustment, or spinal manipulative therapy (SMT).

Chiropractic Manipulative Treatment (CMT) providers use natural and conservative methods to treat the biomechanics, structure and function of the spine, in order to promote healing without surgery or medication.(3) CMT is outcome-based care using specific modalities targeted to the functional problem(s) or diagnosis of the patient. Manipulation or adjustment procedures are performed by manual methods only or with device-assisted modalities, to treat symptoms related to the articulations of the spine and musculoskeletal structures, including the extremities. The goal of CMT is relief of discomfort caused by impingement of nerves or other structures of the spinal column (e.g., joints, tissues, muscles)*.

Chiropractic services that may be eligible for coverage are limited to treatment to correct a structural imbalance or subluxation related to distortion or misalignment of the vertebral column by means of manual spinal manipulation (i.e., by use of the hands) when the condition meets the medical necessity criteria in this policy. Chiropractors may use manual devices/instruments (devices that are hand-held with the thrust or the force of the device being controlled manually) in performing manual manipulation of the spine and related muscles/tissues.

*Specific states’ chiropractic practitioner scope of practice laws govern the extent of the interventions a provider can perform.

Adjunct Modalities

Both active and passive modalities are used as adjunct treatments. Passive modalities are most effective during the acute phase of treatment, as they are typically directed at reducing pain and swelling. The modalities include but are not limited to treatments such as electrical stimulation, therapeutic ultrasound, high-voltage galvanic stimulation, therapeutic heat, cryotherapy, passive exercise, traction, diathermy and massage. When passive modalities are used after a lasting physiological benefit has been reached, the modalities serve only to facilitate the manipulation, are considered integral to the manipulative procedure, and are preparatory or complementary to the chiropractic adjustment.

Active modalities include increasing range of motion, strengthening, and increasing endurance capabilities of the muscles. Progressive resistive exercises are considered an active modality. Some active modalities focus on patient education and training (e.g., back school, work hardening programs, vocational rehabilitation programs, weight training, endurance training) and may not be covered by health plan benefits.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This policy does not apply to Medicare Advantage.

Benefit Application

In some plans, the contract benefit for Chiropractic/Spinal Disorders may be generally described as treatment for bone and joint disorders but other plans specifically define this benefit as applying to misalignment or dislocation of the spine.

Chiropractic care may be explicitly excluded under some benefit plans. In addition, chiropractic care provided to treat an injury or condition that occurred in the workplace, during a motor vehicle accident or involves third party liability may require coordination of benefits.

Please refer to the member’s benefit plan and specific state where the care is received to determine any coverage limitations.

Please refer to specific state licensure information for chiropractic providers if there is a question about the chiropractor’s scope of practice and/or current (active) state licensure.

Rationale

This policy was originally created in 2006 and updated regularly as required based on searches of the MEDLINE database. The most recent literature search was performed in January 2014.The following is a summary of the key literature to date.

Korthals and colleagues conducted a randomized controlled trial (RCT) of 183 patients with neck pain whom were randomly allocated to manual therapy (spinal mobilization), physiotherapy (mainly exercise) or general practitioner care (counseling, education and drugs) in a 52 week study. The clinical outcomes measured showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care. Total costs of the manual therapy treated patients were about one-third of the costs of physiotherapy or general practitioner care up to 26 weeks. (4) However, differences were negligible by follow-up at 52 weeks. The authors concluded that manual therapy is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.

Hondras and colleagues evaluated the evidence for the effects of manual therapies for treatment of patients with bronchial asthma. (5) The authors searched for trials in databases, assessed bibliographies from included studies, and contacted authors of known studies for additional information about published and unpublished trials. Trials were included if they were randomized; included asthmatic children or adults; examined one or more types of manual therapy; and, included clinical outcomes with observation periods of at least two weeks. The authors concluded there is insufficient evidence to support the use of manual therapies for patients with asthma. There is a need to conduct adequately-sized randomized clinical trials.

Panton and colleagues evaluated resistance training (RES) and RES combined with chiropractic treatment (RES-C) on fibromyalgia (FM) impact and functionality in women with FM. A randomized controlled trial was designed to assess participants who were assigned to the RES (n=10) or the RES-C (n=11) group. Both groups completed 16 weeks of RES consisting of 10 exercises performed two times per week. RES-C received RES plus chiropractic treatment two times per week. The outcome measures included strength measurement, which was assessed using one repetition maximum for the chest press and leg extension. FM impact was measured using the FM impact questionnaire, myalgic score, and the number of active tender points. Functionality was assessed using the 10-item Continuous Scale Physical Functional Performance test. Five participants from the RES group discontinued the study. One participant from the RES-C group discontinued the study. Adherence to training was higher in RES-C (92%) than in RES (82%). Additionally, the study found that progressive resistance training two times/week for 16 weeks improves strength, FM impact, and functionality. When chiropractic treatment is added to a resistance training program, adherence and dropout rates are improved as well as pre to post improvement of flexibility, balance and coordination, and endurance. Both groups increased upper and lower body strength. There were similar improvements in FM impact in both groups. Both groups improved in the strength domains; however, only RES-C participants significantly improved in the pre-to post functional domains flexibility, balance and coordination and endurance. (6) One of the limitations of the study is dealing with such a small group of participants which cannot be generalized to a larger population of FM patients. Another limitation is that it was not designed to evaluate chiropractic treatment independently of the exercise program.

Rubinstein and colleagues (2011) reported in 2012 on a Cochrane Database Systematic Review that assessed the effects of Spinal Manipulative Therapy (SMT) for acute low back pain, defined as pain lasting less than six weeks. (7) Randomized controlled clinical trials (RCTS) were included up to March 2011. RCTs that examined spinal manipulation or mobilization in adults with acute low back pain not caused by an underlying condition (e.g. fracture, tumor, infection) were included. Primary outcomes were pain, functional status and perceived recovery. Twenty RCTs (total participants n=2674) were included. The authors concluded that one-third of the trials were considered of high methodological quality and provided a high level of confidence in the outcome of SMT. Generally the authors found low to very low quality evidence suggesting that SMT is no more effective in the treatment of patients with acute low-back pain than inert interventions, sham (or fake) SMT, or when added to another treatment such as standard medical care. SMT also appears to be no more effective than other recommended therapies. SMT appears to be safe when compared to other treatment options but other considerations include costs of care.

Walker and colleagues performed a Cochrane systematic review of randomized controlled trials reviewing combined chiropractic interventions for low-back pain. (8) The outcomes they examined were the effects of chiropractic interventions on pain, disability back-related function, overall improvement, and patient satisfaction. They included 12 studies involving 2887 low back pain participants. The authors concluded that combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute low back pain. However, they found no evidence to support or refute that the interventions provide a clinically difference for pain or disability when compared to other interventions.

Ernst reports that many chiropractors believe that chiropractic treatments are effective for gastrointestinal disorders (GI). (9) The author performed a systematic review to evaluate the evidence from controlled clinical trials supporting or not supporting this notion. Two prospective, controlled clinical trials were found and one of these was a pilot study, but the other had reached a positive conclusion. However, the author concluded that due to serious methodological flaws, there is no supportive evidence that chiropractic treatment is an effective treatment for GI disorders.

Agreement on standardized parameters of chiropractic care for low back pain has been a challenge for the profession. Globe and colleagues in 2008 attempted to incorporate chiropractic research and clinical experts’ experience into a document with chiropractic guidelines and practice parameters. Development of the document started with seed materials, from which seed statements were developed and distributed to a Delphi panel. The panel consisted of 40 clinically experienced doctors of chiropractic, representing 15 chiropractic colleges and 16 states, including the American Chiropractic Association and the International Chiropractic Association. The panel reached 80% consensus of the 27 seed statements after 2 rounds. Specific recommendations regarding treatment frequency and duration, as well as outcome assessment and contraindications for manipulation were agreed on by the panel and detailed in the article. The authors concluded that a broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience. (10)

References

  1. Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD) for Chiropractic Services (L23711) Retired 02/27/12. Last accessed January 27, 2014.
  2. American Chiropractic Association (ACA). Public Policies-Documentation, Arlington, VA: ACA; 2012. Available online at: http://www.acatoday.org/level2_css.cfm?T1ID=10&T2ID=117. Last accessed January 27, 2014.
  3. American Chiropractic Association (ACA). Spinal Manipulation Policy Statement (Updated 2003). Last accessed January 27, 2014.
  4. Korthals-de Bos IB, Hoving JL van Tulder MW et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomized controlled trial. BMJ 2003; 326(7395):911.
  5. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev 2005; (2):CD001002.
  6. Panton LB, Figueroa A, Kingsley JD et al. Effects of resistance training and chiropractic treatment in women with fibromyalgia. J Altern Complement Med. 2009 Mar; 15(3):321-8.
  7. Rubinstein SM, Terwee CB, Assendelft WJJ et al. Spinal manipulative therapy for acute low-back pain. Cochrane Database Syst 4 March 2012 CD008880. Available online at: http://summaries.cochrane.org/CD008880/spinal-manipulative-therapy-for-acute-low-back-pain. Last accessed January 27, 2014.
  8. Walker BF, French SD, Grant W et al. A Cochrane review of combined chiropractic interventions for low-back pain. Spine (Phila Pa 1976). 2011 Feb 1; 35(3):230-42.
  9. Ernst E. Chiropractic treatment for gastrointestinal problems: a systematic review of clinical trials. Can J Gastroenterol. 2011 Jan; 25(1):39-40.
  10. Globe GA, Morris CE et al. Chiropractic management of low back disorders: report from a consensus process. J Manipulative Physiol Ther. 2008 Nov-Dec; 31(9):651-8.
  11. Last reviewed by practicing doctor of chiropractic in January 2014.

Additional resources and websites:

  1. Christensen ST, Hartvigsen J. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manipulative Physiol Ther.2008 Nov-Dec; 31(9):690-714. Last accessed January 27, 2014.
  2. Haldeman S et al. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: executive summary. Spine 2008; 33:S5–S7.
  3. Hurwitz EL et al. Treatment of neck pain: noninvasive interventions. Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33:S123-S152.
  4. Millan M, Leboeuf-Yde C, Budgell B, Amorim MA. The effect of spinal manipulative therapy on experimentally induced pain: a systematic literature review. Chiropr Man Therap. 2012;20(1):26. Epub 2012 Aug 10.
  5. MCG (formerly Milliman Care Guidelines): 17th Edition, Inpatient and Surgical Care, Spinal Manipulation Therapy (SMT), Chiropractic and Other, ACG: A-03331(AC). Available online at: http://careweb.careguidelines.com/ed16/index.htmlhttp://careweb.careguidelines.com/ed17/index.html. Last accessed January 27, 2014.
  6. Medicare Benefit Policy Manual. Chapter 15 - Covered Medical and Other Health Services. Section 30.5, Chiropractor’s Services. Available online at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf . Last accessed January 27, 2014.
  7. National Guideline Clearinghouse. Chiropractic Best Practices and practice guidelines NGC-7125, 2008. Available online at: http://guidelines.gov/content.aspx?f=rss&id=14231. Last accessed January 27, 2014.

Coding

Codes

Number

Description

CPT

97112

Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

 

97140

Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

 

98940

Chiropractic manipulative treatment (CMT); spinal, one or two regions

 

98941

spinal, three to four regions

 

98942

spinal, five regions

 

98943

extraspinal, one or more regions

Type of Service

Rehabilitation Therapy

 

Appendix

 

History

Date

Reason

05/09/06

Add to Therapy Section - New Policy

06/23/06

Update Scope and Disclaimer - No other changes.

06/12/07

Replace Policy - Policy updated with literature review; policy statement updated to include thermomechanical massage as investigational. References added and codes updated. Reviewed by practicing doctor of chiropractic in May 2007.

10/9/07

Cross References Updated - No other changes.

04/08/08

Cross References Updated - No other changes

06/10/08

Replace Policy - Policy updated with literature search; no change to the policy statement. Reviewed by practicing doctor of chiropractic in May 2008.

05/12/09

Replace Policy - Policy updated with literature search. Policy statement added “Restoration of spinal curves as the determinant as a means to treat spinal pain or to normalize spinal curves in asymptomatic patients is not medically necessary”. References added.

05/11/10

Replace Policy - Policy updated with literature search; no change to the policy statement. Reviewed by practicing doctor of chiropractic in April 2010.

12/21/10

Cross References Updated - No other changes.

05/10/11

Replace Policy - Policy updated with literature search; references added; no change to the policy statement. Reviewed by practicing doctor of chiropractic in April 2011.

05/22/12

Replace policy. Policy reviewed by practicing doctor of chiropractic April 2012. Simplified documentation details per legal request. Policy statements unchanged.

10/26/12

Update Related Policies. Title for 8.03.502 has been changed to say “Medical Massage Therapy”.

01/29/13

Replace policy. Policy guidelines have new header for definitions, clarifying statement added about timeframe for initial POT in the documentation requirements paragraph, added the bullet “anticipated date of discharge” to the care plan & follow-up visit paragraphs, the word “re-evaluation” is deleted from the paragraph about follow-up visits. Description and rationale sections updated based on a literature review through November 2012. References 10, 15, 16 added, others renumbered or removed. New section added with additional resources and websites not cited in the policy. Policy statement unchanged.

02/24/14

Replace policy. Revised policy statement language from “is considered” to “may be considered” for consistency with other medical policies. Documentation for follow-up visits in the Policy Guidelines is revised based on vetting with a chiropractic consultant. Definition of terms moved from the Appendix to the Policy Guidelines. Related policy 7.01.551 Lumbar Spine Decompression Surgery added. Rationale reviewed/updated with a literature search through January 27, 2014. Resources 3,4 added; others renumbered. Coding section revised; ICD-9 Diagnosis codes not used for adjudication of this policy so they have been removed. Policy statements changed as noted.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
©2014 Premera All Rights Reserved.