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Medical Policy

Policy Num:      10.002.001
Policy Name:    CHIROPRACTIC SERVICES 
Policy ID:          [10.002.001]  [Ar / L / M+ / P-] [0.00.00]

Last Review:      September 11, 2024 
Next Review:      Policy Archived
 

Related Policies: None

CHIROPRACTIC SERVICES 

Summary

The primary mode of chiropractic treatment is manual or instrument-assisted manipulation or adjustment. Chiropractic manipulation is the application of a controlled, specific, and gentle force to re-establish normal articular function. The objective of the manipulation is to restore the normal mobility and range of motion within the joint.

Objective

Evidence review of manual manipulation in the treatment of musculoskeletal pain when a clear neuromusculoskeletal disorder is identified as causing the problem.

Policy Statements

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

1. The member has a neuromusculoskeletal disorder; and
2. The medical necessity for treatment is clearly documented; and
3. Improvement is documented within the initial 4 weeks of chiropractic care.

Chiropractic manipulations may be considered medically necessary for individuals of 0-4 years old when all of the following criteria are met:

1. The member has a neuromusculoskeletal disorder related to the cervical region; and
2. The medical necessity for treatment of the cervical region is clearly documented; and
3. Improvement is documented within the initial 4 weeks of chiropractic care.

Chiropractic manipulations for individuals 0-4 years old with any other conditions is considered investigational.

If no improvement is documented within the initial 4 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.

Once the maximum therapeutic benefit has been achieved, continuing chiropractic care is considered not medically necessary.

Chiropractic manipulation in asymptomatic persons or in persons without an identifiable clinical condition is considered not medically necessary.

The fact that there is a symptom of "pain" is not sufficient to justify medical necessity.  Misalignment of a peripheral joint or vertebral misalignment should be documented by X-rays and/or complete physical examination.

Manipulation is considered experimental or investigational when it is rendered for non-neuromusculoskeletal conditions (e.g., attention-deficit hyperactivity disorder, asthma, autism spectrum disorder, rheumatologic pain, depression, dizziness/vertigo, dysmenorrhea, epilepsy, female infertility, gastro-intestinal disorders, improvement of brain function, and menopause-associated vasomotor symptoms, muscular dystrophy, multiple sclerosis, pneumonia, and pulmonary emphysema; not an all-inclusive list) because its effectiveness for these indications is unproven.

Manipulation of infants is considered experimental and investigational for non-neuromusculoskeletal indications (e.g., infants with gastro-intestinal disorders including constipation, excessive intestinal gas, and gastroesophageal reflux disease).

Preventive manipulation services are not considered for payment, regardless of the age of the patient.

Chronic cases lasting more than 12 weeks and maintenance therapies are not considered for payment. 

Only acute cases and exacerbations of chronic cases will be covered. The Acute Treatment (AT) modifier was developed to clearly define the difference between acute treatment and maintenance treatment and is required for reporting Chiropractic Manipulations.

An acute condition is considered when:

• is a new complaint, lasting less than 4 weeks, evidenced by the date of X-rays or physical examination and when the interval between its first manipulation and the initial evaluation is relatively short or,
• an acute exacerbation of a chronic condition.

It is expected that treatment by the chiropractor produces a substantial improvement in the patient's condition.

The following conditions are not considered for payment:

•           Acute fractures, dislocations, or old fractures with evidence of instability.

•           Neoplasms that involve the spinal column.

•           Infections in the spine that involve the bones or joints.

•           The presence of an aneurysm near an area for manipulation.

•           Critical conditions

X-rays by chiropractors:

There is an approved policy by Triple-S authorizing the offering of benefits in accordance with the request of Cost-Plus groups or biddings.

The law that regulates the practice of chiropractic in Puerto Rico in its Chapter 7, Paragraph 158 (License-Power Conferred) Letter A indicates the following:

Examine and analyze the human body through the use of physical, chemical, electrical, thermal, or ionic radius methods, as well as through the use of X-rays and other imaging studies as the law dictates.

To bill X-rays services, the chiropractor must have the Radiological Health Certification.

X-ray services are covered as long as they are ordered by a physician surgeon or chiropractor as established in the coverage.

The following services are not considered for payment to chiropractors.

•           Laboratory analysis

•           Injection

•           Medications

•           EKG

•           Acupuncture

•           Nutritional Supplements

•           Orthopedic devices

Policy Guidelines

Treatment may consist of several techniques.  Five regions of the spine are recognized for purposes of manipulative treatment.  These regions are:

·         cervical region includes the atlantooccipital joint

·         thoracic region includes costovertebral and costotransversal joints

·         lumbar region

·         sacral region

·         pelvic region includes the sacroiliac joint

Extraspinal regions are:  Head, including temporomandibular joint or TMJ (excludes the atlanto-occipital region).

·         Lower extremities

·         Upper extremities

·         Thoracic cavity (excluding costovertebral and costotransversal joints)

CHIROPRACTIC CPT CODES

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, one or more regions

Each manipulation region treated needs a diagnosis specific to the area being manipulated with support of medical necessity to each area in question. If multiple areas are manipulated each area needs a specific diagnosis code submitted.

For example:

98942 Chiropractic manipulative treatment (CMT); spinal, five regions. Documentation must support that manipulative treatment occurred in five regions of the spine (region as defined by CPT) and one of the following: validated diagnoses for five spinal regions or validated diagnoses for three spinal regions, plus two adjacent spinal regions with documented soft tissue and segmental findings validated. diagnoses for four spinal regions, plus one adjacent spinal region with documented soft tissue and segmental findings.

98942 Chiropractic manipulative treatment (CMT) involving five spinal regions Medical record must document:

1. A complaint involving five spinal regions;

2. an examination of the corresponding spinal regions; AND

3. a diagnosis and manipulative treatment of conditions involving five spinal regions.

For individuals of  0-4 years old:

• Diagnosis must match the anatomical region and symptoms of the patient's neck (i.e. Torticollis).
• For individuals 0-4 years old there is a maximum frequency of 5 manipulations per 90 days, when the policy benefit allows for a limit in services quantity.

NECESSARY DOCUMENTATION

The chiropractor must document the following on your record:

I.          Chief complaint

•           Trauma mechanism

•           Character, Intensity and Frequency of symptoms

•           Initiation and Duration of symptoms

•           Factors that aggravate or improve symptoms

•           Other previous treatments 

II.          Past history

•           Health condition

•           Previous diseases

•           Surgical history

•           Trauma history

•           Other treatments 

III.         Physical examination

•           Musculoskeletal

•           Nervous system

IV.        Diagnosis

V.         Treatment

Benefit Application

Maximum frequency per year may vary depending on the insurer's benefits policy.

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

N/A

Regulatory Status

N/A

Rationale

SPINAL MANIPULATION — Spinal manipulation is a form of manual therapy that involves the movement of a joint near the end of the clinical range of motion. This movement of the joint is frequently accompanied by an audible cracking or popping sound.

Types of manipulation — Spinal manipulation is classified into one of two forms, depending upon the lever arm used to help the practitioner apply the load necessary for the manipulation:

●The first type includes long-lever, low- to high-velocity, or nonspecific manipulations; this form uses one of the long bones of the limbs (frequently the femur) to amplify the load applied by the clinician's hands to one or several spinal joints.

●The second type includes short-lever, high-velocity manipulations, or specific spinal adjustments; this form involves a short, forceful thrust on a specific vertebral transverse process, thereby moving the specific joint.

Postulated mechanisms of benefit — Several hypotheses have been proposed to explain the benefits of manipulation [1,2]:

●Relaxation of hypertonic muscle by sudden stretching

●Disruption of articular or periarticular adhesions

●Unblocking of motion segments that have undergone disproportionate displacements

●Alteration of pain-related reflexes by proprioceptive bombardment

●Changes in central pain pathways

●Reflexive muscle activation due to increased afferent output

Although some research supports each of these hypotheses, there is no convincing evidence proving the pathophysiologic mechanism underlying the benefit of spinal manipulation.

LOW BACK PAIN — Spinal manipulation is used for the treatment of both acute and chronic low back pain.

NECK PAIN AND HEADACHE — After low back pain, neck pain and headache are the next most common symptoms for which spinal manipulative therapy is offered. Together, these symptoms account for about 20 percent of all visits to chiropractors. It is estimated that between 18 and 38 million cervical spine manipulations are performed annually in the United States [3,4].

Efficacy of manipulation for neck pain — We believe the evidence at this time is inconclusive to draw a strong conclusion; however, cervical or thoracic spine manipulation may benefit some patients with nonspecific neck pain. The data supporting the efficacy of spinal manipulation for neck pain are limited by small, generally low-quality studies. A systematic review evaluating 51 trials of cervical and thoracic manipulation and mobilization for neck pain included three studies that compared cervical manipulation with a control group [5]. Among studies comparing multiple sessions of cervical manipulation with education, manipulation provided better pain relief and functional improvement; however, more research is needed to guide optimal treatment choices. The same review also examined thoracic manipulation and found some evidence to support the use of thoracic manipulation for neck pain compared to inactive controls.

RISKS OF SPINAL MANIPULATION — In general, spinal manipulation is felt to be a relatively safe procedure, although it may be associated with a number of minor complaints and, rarely, serious adverse events.

Minor complaints — Minor complaints following spinal manipulation are common, with rates variably reported between 33 and 60 percent [9]. One systematic review of five prospective studies concluded that mild to moderate transient adverse reactions, including dizziness/light headedness, headache, and numbness, occurred in one-half of all patients undergoing spinal manipulation [10]. In the largest series of 19,722 patients, there were no serious adverse events [11]. Minor events such as dizziness/light headedness occurred in up to 16 per 1000 visits immediately following treatment and in 13 per 1000 after seven days. A randomized trial of manipulation for neck pain found that low-velocity mobilization was somewhat less likely than high-velocity manipulation to lead to adverse reactions; however, adverse reactions were common in both groups, occurring in 30 percent of patients [12]. Increased neck pain or stiffness was the most common adverse event, occurring in 25 percent of patients. Compared with younger patients, those >65 years may have a higher rate of adverse events [13].

However, a randomized trial of chiropractic care (involving manipulation and mobilization treatment for 95.5 and 52.6 percent of treated patients) in 183 adult spinal pain patients, in which a control group received sham treatment, found no difference in rates of reported adverse events between treatment and control groups (relative risk [RR] 1.24, 95% CI 0.85-1.81) [14]. The most common reported events were increased pain and muscle stiffness, affecting approximately 30 percent of patients in both treatment and sham treatment groups. No serious adverse events occurred in either group. Thus, minor adverse events reported in observational series are potentially unrelated to the treatment.

Serious adverse events — The most common serious adverse events reported to be associated with spinal manipulation include disk herniation, the cauda equina syndrome, and vertebrobasilar accidents. Estimates of the incidence of these complications vary, ranging from 1 per 2 million to 1 per 400,000 manipulations in one review [15] and up to 1 per 20,000 in another [9]. These estimates are primarily derived from published case reports, case series, and retrospective surveys, all of which may be unreliable due to underreporting and the dependence on recall. No serious adverse event has been reported from any of the published clinical trials of cervical spinal manipulation [16].

Disk herniation and the cauda equina syndrome have been associated with lumbar manipulation [17]. Individuals with a herniated nucleus pulposus or an underlying bleeding disorder are postulated to be at increased risk of the cauda equina syndrome.

Studies of vertebrobasilar dissection or occlusion possibly associated with cervical spine manipulation include case reports, prospective series, and case control studies. While an association has been reported, the causality between manipulation and dissection has not been established. Some reports estimate stroke or vertebrobasilar dissection to occur as infrequently as once per one to three million manipulations [18], while others report an incidence as high as 5 per 100,000 manipulations [9].

●A six-week prospective study of cervical spine manipulation involved 377 chiropractors in Britain (32 percent of the country's chiropractors, although all were invited to participate) and over 19,000 patients and 50,000 cervical manipulations [11]. No serious adverse events were reported by clinicians or patients in this timeframe. However, underreporting was possible both due to loss to follow-up for 413 consultations and to potential bias related to self-reporting.

●A population-based, case-control study found that in patients under the age of 45, those with vertebrobasilar dissection or occlusion were five times more likely than controls to have visited a chiropractor in the previous week and to have had three or more cervical chiropractic visits in the previous month [19]. No association between chiropractic and vertebrobasilar events was found for older individuals.

●A case-control study of patients younger than 60 presenting with a stroke or transient ischemic attack found a higher rate of spinal manipulation within the previous 30 days in patients whose event was due to a vertebral arterial dissection than in patients with an event due to another etiology (odds ratio [OR] 6.62, 95% CI 1.4-30) [20].

●However, another case-control study of vertebrobasilar artery (VBA) stroke in persons under the age of 45 found that patients were three times more likely than controls to have visited either a chiropractor or a primary care clinician prior to their stroke; the authors postulate that visits to either of these healthcare providers are a marker for impending VBA stroke and are likely not causally related to subsequent VBA stroke [21].

A paucity of data exists concerning the risk factors for vertebrobasilar compromise after manipulation [22]. Anecdotal evidence suggests that the risk is higher for manipulation involving rotation plus extension of the cervical spine than for other types of manipulation.

Other — There are many case reports describing complications due to misdiagnosis by providers who perform spinal manipulation, such as failing to correctly diagnose spinal tumors or metastatic disease.

Population Reference No. 1

For individuals with acute musculoskeletal pain. Intervention of interest are manual manipulation – therapy - at affected area. Comparators of interest are other pharmacologic or therapies available. Relevant outcomes include symptom relief, quality of life, treatment related morbidity and functional outcomes.

Population Reference No. 2 

There is insufficient evidence to support the use of chiropractic in treatment of non-neuromusculoskeletal conditions in children.  In a review Chiropractic Diagnosis and Management of Non-musculoskeletal Conditions in Children and Adolescents, Ferrance and Miller (2010) noted that a great deal has been published in the chiropractic literature regarding the response, or lack thereof, of various common pediatric conditions to chiropractic care.  The majority of that literature is of low scientific value (i.e., case reports or case series).  The purpose of this review was to summarize the literature from the point of view of clinicians, rather than researchers, and to discuss some additional detail of the conditions themselves.  Databases searched were PubMed, Mantis, Index to Chiropractic Literature, and CINAHL. Keywords were chiropractic paired with colic, crying infant, nocturnal enuresis, asthma, otitis media and ADHD.  Most of the published literature centers around case reports or series.  The more scientifically rigorous studies show conflicting results for colic and the crying infant, and there is little data to suggest improvement of otitis media, asthma, nocturnal enuresis or attention deficit hyperactivity disorder.  The authors concluded that the efficacy of chiropractic care in the treatment of non-musculoskeletal disorders has yet to be definitely proven or disproven, with the burden of proof still resting upon the chiropractic profession.

Manipulation of more than one region for individuals of 0-4 years old is considered investigational for all conditions (e.g., infants with gastro-intestinal disorders including constipation, excessive intestinal gas, and gastroesophageal reflux disease). 

Chiropractic manipulations in this age group has shown conflictive results among different studies.  Clinical input on this topic in general agree that cervical manipulations in this age group may improve the general quality of life (i.e. Torticollis, latching improvement, etc.)

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

A55225 (Chiroparctor Services New Part A and Part B LCD).

Non Coverage Guideline Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943), which includes the head, upper and lower extremities, rib cage and abdomen.

References

1. 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; 20:26.
2. Maigne JY, Vautravers P. Mechanism of action of spinal manipulative therapy. Joint Bone Spine 2003; 70:336.
3. Shekelle PG, Brook RH. A community-based study of the use of chiropractic services. Am J Public Health 1991; 81:439.
4. Hurwitz EL, Coulter ID, Adams AH, et al. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998; 88:771.
5. Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev 2015; :CD004249.
6. Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database Syst Rev 2004; :CD001878.
7. Hurwitz EL, Morgenstern H, Harber P, et al. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. Am J Public Health 2002; 92:1634.
8. Bergman GJ, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med 2004; 141:432.
9. Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: a systematic review. Spine (Phila Pa 1976) 2009; 34:E405.
10. Ernst E. Prospective investigations into the safety of spinal manipulation. J Pain Symptom Manage 2001; 21:238.
11. Thiel HW, Bolton JE, Docherty S, Portlock JC. Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine (Phila Pa 1976) 2007; 32:2375.
12. Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study. Spine (Phila Pa 1976) 2005; 30:1477.
13. Whedon JM, Mackenzie TA, Phillips RB, Lurie JD. Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66 to 99 years. Spine (Phila Pa 1976) 2015; 40:264.
14. Walker BF, Hebert JJ, Stomski NJ, et al. Outcomes of usual chiropractic. The OUCH randomized controlled trial of adverse events. Spine (Phila Pa 1976) 2013; 38:1723.
15. Stevinson C, Ernst E. Risks associated with spinal manipulation. Am J Med 2002; 112:566.
16. Carlesso LC, Gross AR, Santaguida PL, et al. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review. Man Ther 2010; 15:434.
17. Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for low-back pain. Ann Intern Med 1992; 117:590.
18. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine (Phila Pa 1976) 1996; 21:1746.
19. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke 2001; 32:1054.
20. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 2003; 60:1424.
21. Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976) 2008; 33:S176.
22. Hufnagel A, Hammers A, Schönle PW, et al. Stroke following chiropractic manipulation of the cervical spine. J Neurol 1999; 246:683.
23. Current Procedural Terminology(CPT), American Medical Association(AMA)
24. First Coast Service Options, Inc.MAC Part B. Local Coverage Article: Billing and Coding: Chiropractic Services (A58412) Accessed August, 2021.
25. Wolff, R. Torticollis. Boston Children’s Hospital. 2012.
26. Hawk, C., Schneider, M. J., Vallone, S., & Hewitt, E. G. (2016). Best practices for chiropractic care of children: a consensus update. Journal of manipulative and physiological therapeutics, 39(3), 158-168.
27. Lacerte, F., & DC, D. Positive outcome from a chiropractic multidisciplinary approach for congenital torticollis in an infant three-weeks of age: A case report. JOURNAL OF CLINICAL CHIROPRACTIC PEDIATRICS, 1638.

Codes

Applicable Modifiers

Modifier AT required.

Policy History