Latest Review Date: October 2023

Category: Therapy                                 

POLICY

I.   Initial Evaluation and Treatment

Chiropractic services may be considered medically necessary for rehabilitative therapy when all of the following criteria are met:

• Care is provided or directed by a licensed Doctor of Chiropractic; AND
• Initial evaluation has been completed that includes all of the following:
  • Current musculoskeletal condition (spinal or extraspinal) for which patient is seeking treatment (e.g., back pain, neck pain, cervicogenic headache, limited joint range of motion); AND
  • Past health history, current treatment being received from other health care providers and social history pertinent to current problem; AND
  • Objective results of a complete physical examination pertinent to the current problem; AND
  • Documented functional impairment; AND
  • Diagnosis: 
    • Accurately reflects patient’s primary complaint and primary reason for presenting for care; AND
    • Is supported by documented subjective and objective findings. AND
• Treatment plan addresses all of following:
  • Type of care, duration, frequency and process for evaluating successful treatment; AND
  • Specific, measurable goals for discharge; AND
  • Individual patient education needs including active participation by the patient (i.e., home exercise program). AND
• Manual manipulation meets one of the following:
  • Single spinal region; OR
  • Multiple spinal regions supported by documented evidence of current condition(s) in multiple regions; OR
  • Extraspinal manipulation supported by documented evidence of a current condition of the other region(s) that require chiropractic treatment.

II.   Continued Treatment

Continued treatment may be considered medically necessary when all of the following criteria are met:

• Criteria for initial treatment are met; AND
• One of the following are met:
  • Chiropractic services have resulted in positive clinical response demonstrated by one of the following:
    • Decreased use of pain medication, OR
    • Objectively measured improvement of function or stabilization of functional decline indicated by measures at the onset of treatment and measures at subsequent follow-up treatments using validated tools (e.g., PROMIS Pain Interference Form, Neck Disability Index, Oswestry Disability Index, Pain Disability Index, and Roland Morris Back Pain Disability Questionnaire); OR
  • Diagnostic reevaluation has resulted in change of treatment approach based on new and relevant information.

III. Discharge Criteria

Continuing treatment is considered not medically necessary when any of the following criteria are met:

• No improvement in a patient’s condition after the 12 most recent chiropractic treatments unless reevaluation results in revised diagnosis and updated treatment plan; OR
• Care is maintenance, preventive or supportive in nature and therefore does not meet the definition of rehabilitative therapy; OR
• Symptomatology and/or functional impairment have resolved; OR
• Insufficient clinical evidence to support the current diagnosis; OR
• Patient has reached a level at which no further improvement can reasonably be expected.

IV.  Not Medically Necessary

The following are considered not medically necessary:

• Full spine radiographic views for any diagnosis other than scoliosis of the spine
• Treatment of scoliosis progression and/or reducing curvature
• Digital radiographic mensuration analysis for assessing spinal malalignment
• Chiropractic manipulations for preventative reasons such as V-code diagnoses, wellness visits or as a substitute for vaccination
• Services rendered primarily to meet goals of weight loss

V.   Investigational

Chiropractic services performed for non-musculoskeletal conditions including but not limited to the following are considered investigational due to a lack of clinical evidence demonstrating an impact on improved health outcomes:

• Attention-deficit hyperactivity disorder
• Allergies
• Asthma
• Autism spectrum disorder
• Cancer Cerebral palsy
• Difficulty nursing in infants
• Dysmenorrhea
• Epilepsy
• Gastro-intestinal disorders, including constipation in infants
• Infantile colic
• Infectious disease including but not limited to otitis media, common cold or sinus infection
• Nocturnal enuresis
• Sleep disturbances

Documentation Submission:

Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization when prior authorization is required. In addition, the following documentation must also be submitted:

• Initial Evaluation and Treatment
  • Clinical notes describing the diagnosis and clinical features of the diagnosis.
  • Radiology/imaging studies.
  • Manipulation of region(s) of spine documented in the treatment record.
  • Multiple manipulations and/or extraspinal manipulations must also be supported by documented evidence of a current condition of the other region(s), which require chiropractic treatment.
• Continued Treatment
  • Current symptoms and/or functional impairment that have measurably improved with chiropractic care but have continued. Improvement with additional chiropractic care can be reliably predicted.
  • Diagnostic reevaluation resulting in change of treatment approach based on new and relevant information.

DESCRIPTION OF PROCEDURE OR SERVICE

Minnesota statute 148.01, which defines chiropractic services, includes the evaluation and treatment of structural, biomechanical and neurological function and integrity through the use of adjustment, manipulation, mobilization or other procedures accomplished by manual or mechanical forces applied to bones or joints and their related soft tissues. The goal of chiropractic services is to correct vertebral subluxation or other abnormal articulations, neurological disturbances, structural alterations or biomechanical alterations.

Minnesota Rule 2500.0100 Subpart 11 defines rehabilitative therapy performed by a chiropractor as “Therapy that restores an ill or injured patient to the maximum functional improvement by employing within the practice of chiropractic those methods, procedures, modalities, devices, and measures which include mobilization; thermotherapy; cryotherapy; hydrotherapy; exercise therapies; nutritional therapy; meridian therapy; vibratory therapy; traction; stretching; bracing and supports; trigger point therapy; massage and the use of forces associated with low voltage myostimulation, high voltage myostimulation, ultraviolet light, diathermy, and ultrasound; and counseling on dietary regimen, sanitary measures, occupational health, lifestyle factors, posture, rest, work, and recreational activities that may enhance or complement the chiropractic adjustment.”
Maintenance therapy is defined by the Centers of Medicare and Medicaid Services (CMS) 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.”

Blue Cross Blue Shield of Minnesota has additional policies on specific tests and treatments related to chiropractic services. These include but are not limited to the following (policy numbers in parentheses):

• Dynamic Posturography (MP 268)
• Dynamic Spinal Visualization and Vertebral Motion Analysis (MP 511)
• Low-Level Laser Therapy and High-Power Laser Therapy (MP 270)
• Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain (MP 362)
• Vertebral Axial Decompression (MP 484)
• Evoked Potential Studies (MP 395)

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.

ITS: Covered if covered by the Participating Home Plan

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.

CURRENT CODING:

CPT Codes:

POLICY HISTORY

Reviewed and posted July 1, 2021

October 2021: Annual review completed.  No change to policy intent.

October 2022:  Annual review completed.  No change to policy intent.

October 2023: Annual review completed.  No change to policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1.  The technology must have final approval from the appropriate government regulatory bodies;
2.  The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3.  The technology must improve the net health outcome;
4.  The technology must be as beneficial as any established alternatives;
5.  The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1.  In accordance with generally accepted standards of medical practice; and
2.  Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3.  Not primarily for the convenience of the patient, physician or other health care provider; and
4.  Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.