CHIROPRACTIC SERVICES HS-217
Easy Choice Health Plan, Inc.
Harmony Health Plan of Illinois, Inc.
Missouri Care, Inc.
‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.
WellCare Health Insurance of Illinois, Inc.
WellCare Health Plans of New Jersey, Inc.
WellCare Health Insurance of Arizona, Inc.
WellCare of Florida, Inc.
WellCare of Connecticut, Inc.
WellCare of Georgia, Inc.
WellCare of Kentucky, Inc.
WellCare of Louisiana, Inc.
WellCare of New York, Inc.
WellCare of South Carolina, Inc.
WellCare of Texas, Inc.
WellCare Prescription Insurance, Inc.
Windsor Health Plan
Windsor Rx Medicare Prescription Drug Plan
Chiropractic Services
Policy Number: HS-217
Original Effective Date: 2/17/2014Revised Date(s): 2/5/2015 APPLICATION STATEMENT
The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.
CHIROPRACTIC SERVICES HS-217
DISCLAIMER
The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult www.wellcare.com/Providers/CCGs for list of current LOBs.
BACKGROUND
A licensed chiropractor who meets uniform minimum standards (see subsection C) is a physician for specified services.
Coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by X-ray, provided such treatment is legal in the State where performed. All other services furnished or ordered by chiropractors are not covered. An X-ray obtained by a chiropractor for his or her own diagnostic purposes before
commencing treatment may suffice for claims documentation purposes. This means that if a chiropractor orders, takes, or interprets an X-ray to demonstrate a subluxation of the spine, the X-ray can be used for claims processing purposes.
However, there is no coverage or payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the chiropractor. In addition, in performing manual manipulation of the spine, some chiropractors use manual devices that are hand-held with the thrust of the force of the device being controlled manually. While such manual
manipulation may be covered, there is no separate payment permitted for use of this device. (CMS, 2009).
Chiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function.
This treatment may be accomplished using a variety of techniques. Medicare covers limited chiropractic services when performed by a chiropractor who is licensed or legally authorized to furnish chiropractic services by the State or jurisdiction in which the services are furnished (CMS Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 70.6). A chiropractor must also meet uniform minimum standards as set forth in the CMS Internet-Only Manual (IOM) Publication 100-1, Chapter 5, Section 70.6. This policy restates language directly from the CMS Internet-Only manuals and if necessary provides clarification. (CMS, 2013).
POSITION STATEMENT
For Craniosacral Therapy and Osteopathic Manipulative Treatment (OMT), refer to CCG HS-128.
Note: Refer to InterQual Outpatient Chiropractic criteria; this guideline is to be consulted for additional market specific criteria.
Applicable To:
Medicaid – Florida Medicaid – Hawaii Medicaid – Illinois Medicaid – Kentucky Medicaid – New Jersey Medicaid – New York Medicaid – South Carolina
* Includes Routine Services
Medicare – Connecticut Medicare – California Medicare – Florida*
Medicare – Georgia Medicare – Hawaii Medicare – Illinois Medicare – Kentucky Medicare – Louisiana Medicare – New Jersey*
Medicare – New York*
Medicare – Texas Medicare – Windsor
CHIROPRACTIC SERVICES HS-217
Medical Necessity Criteria
Chiropractic services are considered medically necessary for Medicaid and Medicare members when ALL of the following criteria are met:
Services will support the reasonable expectation of recovery or improvement that supports the start and continuation of a therapeutic level care plan; AND,
Treatment follows an acute care model and be episodic in nature in which improvement is documented within the initial 2 weeks of chiropractic care*; AND,
Services are performed by a licensed doctor of chiropractic who and adheres to the laws and regulations of the state the provider is licensed.
* Once a member has stabilized or reached a member’s condition is neither regressing nor progressing (maximum medical improvement (MMI), the member may not meet medically necessary criteria.
If no improvement is documented within the initial 2 weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified.
If no improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary.
Services must be included in an ongoing, written plan of care (POC) that applied to all state and federal laws and regulations. In addition, professional standards of care should also be adhered to. The POC should detail objective and subjective data of the member’s status, demonstrating the medical necessity of the suggested treatment. The following should be included in the POC:
Documented evidence of a significant neuromusculoskeletal condition that creates a functional impairment requiring a medically necessary evaluation and necessary treatment; AND,
Initial evaluation/assessment/history and physical; AND,
Goals (long and short term) that are measurable and objective; AND,
An expected timeframe of when the goals will be achieved; AND,
Chiropractic techniques, treatments or exercises that will be used as well as the spinal and/or body region to be targeted; AND
Frequency and duration of treatment(s) that are reasonable and customary under national standards of practice for chiropractic care; AND,
Documentation of clinically indicated and medically necessary services (per subscriber certificate(s)).
MEDICARE
Chiropractic services are a covered benefit when the Medically Necessity Criteria is met (see pp. 2-3). Services include manual manipulation of the spine to correct subluxation. Some markets routine services to support the back, neck, or joints of the arms and legs. These services go beyond what is covered under standard Medicare.
Routine care is limited by medical necessity and not available in all markets. See market specific criteria below, including the number of allowable visits (where applicable).
Arizona, California, Connecticut, Georgia, Hawaii, Illinois, Kentucky, Louisiana, Missouri, Ohio, Texas (Medicare)
Chiropractic therapy is based on the interactions of the spine and nervous system. Chiropractic services are most often used to treat complaints of back pain, neck pain, pain in the joints of the arms or legs, and headaches.
Chiropractic services are a covered benefit for manipulation of the spine when the Medically Necessity Criteria listed on page 3 is met. Services are medically necessary to correct a subluxation (when one or more of the bones of your spine moves out of position). Treatment must be provided by chiropractors or other qualified providers as
CHIROPRACTIC SERVICES HS-217
specified by state regulations.
Coverage is not capped and driven solely by medical necessity.
Exclusions
The following are non-covered benefits:
X-rays or physical therapy provided by chiropractors.
Chiropractic services when treatment becomes supportive rather than corrective in nature, meaning that clinical improvement cannot reasonably be expected from continuous ongoing care. This includes routine services as specified on page 2.
Florida (Medicare)
Chiropractic therapy is based on the interactions of the spine and nervous system. Chiropractic services are most often used to treat complaints of back pain, neck pain, pain in the joints of the arms or legs, and headaches.
Chiropractic services are a covered benefit for manipulation of the spine when the Medically Necessity Criteria is met (see pp. 2-3). Services may include correction of a subluxation (when one or more of the bones of your spine moves out of position). Treatment must be provided by chiropractors or other qualified providers as specified by state regulations.
Coverage includes 24 visits per year.
Exclusions
The following are non-covered benefits:
X-rays or physical therapy provided by chiropractors.
Chiropractic services when treatment becomes supportive rather than corrective in nature, meaning that clinical improvement cannot reasonably be expected from continuous ongoing care.
New Jersey and New York (Medicare)
Chiropractic therapy is based on the interactions of the spine and nervous system. Chiropractic services are most often used to treat complaints of back pain, neck pain, pain in the joints of the arms or legs, and headaches.
Chiropractic services are a covered benefit for manipulation of the spine when the Medically Necessity Criteria is met (see pp. 2-3). Services may include correction of a subluxation (when one or more of the bones of your spine moves out of position). Treatment must be provided by chiropractors or other qualified providers as specified by state regulations.
Coverage includes unlimited visits each year.
Exclusions
The following are non-covered benefits:
X-rays or physical therapy provided by chiropractors.
Chiropractic services when treatment becomes supportive rather than corrective in nature, meaning that clinical improvement cannot reasonably be expected from continuous ongoing care.
CHIROPRACTIC SERVICES HS-217
MEDICAID
FLORIDA - Medicaid
Chiropractic services are a covered benefit for manipulation of the spine when the Medically Necessity Criteria is met (see pp. 2-3). Services include evaluation and medically necessary treatment is performed on one or more areas of the body. Treatment consists of manual manipulation or adjustment with application of controlled force to re- establish normal articular function. Manual manipulation is used to restore optimum mobility and range of motion to the spine. Services are covered through mobile chiropractic units operated by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).
Coverage includes 24 visits per year which can consist of:
Twenty-four (24) established patient visits; OR,
One (1) new patient visit and twenty-three (23) established patient visits.
NOTE: Only one visit per day is allowed.
Exclusions
The following are non-covered benefits:
Experimental and investigational chiropractic interventions.
Manual manipulation performed on patients for non-musculoskeletal conditions.
Manual manipulation performed on patients who are asymptomatic.
Preventive or maintenance chiropractic interventions or manual manipulation.
Chiropractic care provided to a patient whose condition is neither regressing nor improving is not considered medically necessary.
Non-manual or automated mechanical manipulation of the spine.
GEORGIA - Medicaid
Chiropractic services are not a covered benefit.
HAWAII - Medicaid
Chiropractic services are a covered benefit under EPSDT services for members < age 21. The Medically Necessity Criteria on pp. 2-3 must also be met.
Chiropractic services are not a covered benefit for adults > age 21 unless expected to impact a pregnancy outcome and would therefore be considered a pregnancy related service which is not limited.
ILLINOIS - Medicaid
Chiropractic services are a covered benefit for members < age 21. Chiropractic services are a covered benefit for manipulation of the spine when the Medically Necessity Criteria is met (see pp. 2-3). Chiropractic services are not a covered benefit for adults > age 21.
CHIROPRACTIC SERVICES HS-217
KENTUCKY - Medicaid
Chiropractic services are a covered benefit. Members are limited to 26 visits per 12 month period. Chiropractic services are a covered benefit for manipulation of the spine when the Medically Necessity Criteria is met on pp. 2-3.
MISSOURI - Medicaid
Chiropractic services are not a covered benefit.
NEW JERSEY - Medicaid
Chiropractic services are a covered benefit for NJ FamilyCare A, B and C enrollees only. Chiropractic services are a covered benefit for manipulation of the spine when the Medically Necessity Criteria is met (see pp. 2-3).
Chiropractic services are not a covered benefit for NJ FamilyCare D enrollees.
Coverage is limited to spinal manipulation.
NEW YORK - Medicaid
Chiropractic services are a covered benefit for members aged < 21 and under as part of the EPSDT program when such services are ordered by a physician. In addition, the Medically Necessity Criteria listed on pages 2-3 must be met.
Chiropractic services are not a covered benefit for members > age 21.
SOUTH CAROLINA - Medicaid
Chiropractic services are a covered benefit by means of manual manipulation of the spine for the purpose of correcting a subluxation demonstrated on x-ray. Subluxation means an incomplete dislocation, off centering, misalignment, fixation, or abnormal spacing of the vertebrae anatomically that is demonstrable on x-ray. In addition, the Medically Necessity Criteria listed on pages 2-3 must be met.
Members are limited to the following services:
One (1) chiropractic manipulative treatment/procedure per visit and one visit per day, with a maximum of eight (8) visits during the state fiscal year (July 1 – June 30).
Two (2) x-rays per state fiscal year (July 1 – June 30).
NOTE: Chiropractic visits are counted separately from the ambulatory visit limit.
Experimental / Investigational (Medicaid and Medicare)
The following indications for chiropractic services are considered experimental / investigational and not covered:
For manipulations or modalities that are not related to the individual’s symptoms, not likely to result in sustained improvement, or do not have defined endpoints, including maintenance, preventive or supportive care or care provided to prevent reoccurrences or slow deterioration
CHIROPRACTIC SERVICES HS-217
Services provided to reduce potential risk factors where significant improvement is not expected
For duplicated services, when provided by a physical therapist or other health professional
Digital radiographic mensuration
Digital postural analysis
Treatments and programs deemed non-medical or that are educational or training based (e.g., work hardening, vocational rehabilitation, athletic enhancement for performance)
Chiropractic manipulation and adjunct therapeutic procedures/modalities such as mobilization, therapeutic exercise, traction that are sought for treatment of non-neuromusculoskeletal conditions.
In addition, the following procedures are considered experimental / investigational and not covered:
Active Release Technique
Active Therapeutic Movement (ATM2)
Applied Spinal Biomechanical Engineering
Atlas Orthogonal Technique
Bioenergetic Synchronization Technique
Biogeometric Integration
Blair Technique
Chiropractic Biophysics Technique
Coccygeal Meningeal Stress Fixation Technique
Computerized radiographic mensuration analysis for assessing spinal mal-alignment
Cranial Manipulation
Directional Non-force Technique
Dynamic spinal visualization
FAKTR (Functional and Kinetic Treatment with Rehab) Approach
Gonzalez Rehabilitation Technique
Koren Specific Technique
Manipulation for infant colic
Manipulation for internal (non-
neuromusculoskeletal) disorders (Applied Kinesiology)
Manipulation under anesthesia Moire Contourographic Analysis
Network Technique
Neural Organizational Technique
Neurocalometer/Nervoscope
Neuro Emotional Technique
Para-spinal electromyography (EMG)/Surface scanning EMG
Sacro-Occipital Technique
Spinal adjusting devices (ProAdjuster, PulStarFRAS, Activator)
Spinoscopy
Thermography
Upledger Technique and Cranio-Sacral Therapy
Webster Technique (for breech babies)
Whitcomb Technique
CODING
FLORIDA MEDICAID
Medicaid reimburses the following procedure codes for follow-up visits:
98940—Chiropractic manipulation treatment (CMT); spinal, one to two regions.
98941—Chiropractic manipulation treatment (CMT); spinal, three to four regions.
98942—Chiropractic manipulation treatment (CMT); spinal, five regions.
98943- Chiropractic manipulation treatment (CMT); extraspinal, 1 or more regions
A provider may not bill for more than one chiropractic manual manipulation treatment procedure code for the same recipient on the same date of service.
Medicaid reimburses chiropractic providers for diagnostic radiology services, identified on the Chiropractic Services Fee Schedule.
Radiology Services Provided in Conjunction with Chiropractic Services
CHIROPRACTIC SERVICES HS-217
A professional component service is the chiropractor’s interpretation and reporting of the radiological exam and is identified by adding a modifier 26 to the procedure code on the claim form.
Medicaid reimburses for the professional component service only when the service is provided in an office, clinic, inpatient hospital or outpatient hospital setting.
If the professional service component is provided for an emergency room recipient, use ―outpatient hospital‖ for place of service on the claim.
The professional component is not reimbursed separately when a chiropractor or members of a group practice perform both the professional component and technical component.
When an x-ray is taken in the emergency room, only one of the following types of service providers can be reimbursed for the professional component:
Practitioner;
MD or DO;
ARNP;
Physician’s Assistant
Emergency room physician;
Chiropractor; or
Radiologist
ILLINOIS - Medicaid
The services covered in the chiropractic program are limited to the treatment of the spine by manual manipulation to correct a subluxation of the spine. The following procedures may be submitted for reimbursement by the
chiropractor:
98940-Chiropractic Manipulative Treatment (CMT): Spinal one or two regions
98941-Chiropractic Manipulative Treatment (CMT): Spinal three or four regions
98942-Chiropractic Manipulative Treatment (CMT): Spinal five regions For each date of service no more than one procedure code may be billed.
KENTUCKY - Medicaid
Chiropractic service shall be reported using:
99201-99205, 99211-99215-An evaluation and management CPT code;
97112, 97116, 97124, 97140, 97260-97261-Therapeutic procedures
98940-98943- chiropractic manipulative treatment CPT code;
71101, 72010, 72020, 72040, 72050,72052, 72070, 72072, 72074, 72080, 72090, 72100, 72110, 72114, 72120, 72170, 73020, 73030, 73070, 73100, 76450, 73130, 73140, 73510, 73140, 73510, 73560, 73565, 73600, 73620, 73630- diagnostic X-ray CPT code; or
Physical modality application CPT codes for the following:
o 97010-Application of a hot or cold pack to one (1) or more areas;
o 97012-Application of mechanical traction to one (1) or more areas;
o 97014Application of electrical stimulation to one (1) or more areas; or o 97035-Application of ultrasound to one (1) or more areas.
CHIROPRACTIC SERVICES HS-217
REFERENCES
1. Agency for Health Care Administration. (2010, January). Florida Medicaid chiropractic services coverage and limitations handbook.
Retrieved from http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/ tabId/39/Default.aspx
2. Centers for Medicare and Medicaid Services. (2013, November 1). Local coverage determination for chiropractic services (L24288) [applies to Arizona]. Retrieved from http://www.cms.hhs.gov/mcd/search.asp
3. Centers for Medicare and Medicaid Services. (2011, November 1). Local coverage determination for chiropractic services (L33518) [applies to California, Hawaii]. Retrieved from http://www.cms.hhs.gov/mcd/search.asp
4. Centers for Medicare and Medicaid Services. (2013, October 25). Local coverage determination for chiropractic services (L27350) [applies to Connecticut, Illinois, New York]. Retrieved from http://www.cms.hhs.gov/mcd/search.asp
5. Centers for Medicare and Medicaid Services. (2012, September 7). Local coverage determination for chiropractic services (L30328) [applies to Missouri]. Retrieved from http://www.cms.hhs.gov/mcd/search.asp
6. Centers for Medicare and Medicaid Services. (2013, January 1). Local coverage determination for chiropractic services (L27480) [applies to New Jersey]. Retrieved from http://www.cms.hhs.gov/mcd/search.asp
7. Centers for Medicare and Medicaid Services. (2011, October 17). Local coverage determination for chiropractic services (L32718) [applies to Louisiana, Texas]. Retrieved from http://www.cms.hhs.gov/mcd/search.asp
8. Centers for Medicare and Medicaid Services. (2012, January 31). Local coverage determination for chiropractic services (L29099) [applies to Florida]. Retrieved from http://www.cms.hhs.gov/mcd/search.asp
9. Centers for Medicare and Medicaid Services. (2011, October 17). Local coverage determination for chiropractic services (L31862) [applies to Kentucky, Ohio]. Retrieved from http://www.cms.hhs.gov/mcd/search.asp
10. Centers for Medicare and Medicaid Services. (2009, March 6). CMS publication 100-01: Medicare general information, eligibility and entitlement manual, chapter 5, section 70.6. Retrieved from http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/ge101c05.pdf
11. Illinois Department of Healthcare and Family Services. (n.d.). Handbook for providers of chiropractic services: chapter B-200. Retrieved from http://www2.illinois.gov/hfs/SiteCollectionDocuments/b200.pdf
12. Kentucky Cabinet for Health and Family Services. (2011). 907 KAR 3:125. Chiropractic services and reimbursement. Retrieved from http://www.lrc.state.ky.us/kar/907/003/125.htm
MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS
Date Action
2/5/2015 Approved by MPC. No changes.
2/17/2014 Approved by MPC.
