Cigna Medical Coverage Policy - Therapy Services Chiropractic Care
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Defines medical necessity, exclusions, coding, and coverage rules for chiropractic care and adjunctive therapy services when covered under Cigna/ASH-administered benefit plans.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically Necessary Chiropractic Services
Covered when ALL of the following are met
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Adjunct Manipulation/Mobilization Coverage
Specific covered adjuncts
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Not Medically Necessary
Services considered NOT medically necessary when ANY of the following apply
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Exclusions and Duplication
Explicit exclusions
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General medical necessity criteria for chiropractic services
Covered when ALL of the following are met
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Evaluation/Reevaluation
Evaluation and reevaluation requirements
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Documentation-based coverage criteria
Covered when documentation demonstrates medical necessity and functional progress
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Experimental / Investigational / Insufficient Evidence
Treatments considered experimental, investigational, or unproven (generally not covered)
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Coverage statements for devices, diagnostics, imaging, and provider qualifications
Coverage statements and criteria as stated in this portion of the guideline:
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Treatment visits that extend beyond 4 timed unit services per date of service per provider (equivalent to one hour) are not covered or reimbursable. Providers should submit services using covered procedure codes and ensure total timed units billed on a single date of service for a single provider do not exceed this limit to avoid denial.
Programs that are primarily educational or vocational in nature (for example, back school, vocational rehabilitation, or work hardening programs) are generally excluded or considered not medically necessary under many benefit plans and should not be submitted as covered chiropractic treatment services.
Certain modalities and therapeutic procedures are considered duplicative and it is inappropriate to perform or bill them during the same treatment session when they have overlapping physiologic effects. Examples include functional activities and ADLs billed together, more than one deep heating modality, massage therapy and myofascial release, orthotics and prosthetic training, and whirlpool and Hubbard tank.
When neuromuscular reeducation, therapeutic exercises, and therapeutic activities are provided on the same day, the medical necessity for each must be documented in the medical record; similarly, co-provided services across disciplines must be distinct, justified, and supported by separate evaluations, treatment plans, and goals to avoid being considered duplicative.
Diagnostic thermography performed with handheld contact or thermocouple devices (for example, liquid crystal contact methods or thermocouple instruments such as the neurocalometer or Nervoscope) is considered experimental, investigational, and not medically necessary for any condition. Only diagnostic infrared thermography conducted under controlled conditions (special climate-controlled room) may be considered for specific indications.
Spinal manipulation for non‑musculoskeletal conditions is not supported by sufficient evidence and is considered experimental, investigational, or unproven. The policy specifically lists conditions (e.g., asthma, ADHD, autism spectrum disorders, dysmenorrhea, hypertension, infantile colic, nocturnal enuresis, otitis media) for which spinal manipulation lacks demonstrated clinical effectiveness.
Handheld/contact thermography devices (for example, liquid crystal contact methods, neurocalometer/Nervoscope) are considered experimental and not medically necessary. By contrast, diagnostic infrared thermography performed under controlled conditions in a climate‑controlled environment may be considered medically necessary for select indications.
Surface electromyography (SEMG) is considered experimental and investigational for diagnostic purposes due to insufficient evidence of clinical utility. Additionally, diagnostic ultrasound for nonoperative spinal or paraspinal evaluation is regarded as investigational with no proven clinical utility for these indications.
This portion of the reference section consists of bibliographic citations and does not itself list any additional explicit coverage exclusions beyond those stated elsewhere in the guideline.
Maintenance or preventive care—defined as elective, long‑term services provided to prevent disease or promote general health—is considered not medically necessary under this policy when no therapeutic benefit or objective functional improvement is expected.
Treatments that are not directed at diagnosis or management of musculoskeletal disorders or that are routine education, conditioning, or require only routine supervision (for example, general exercise programs, relaxation massage, or whirlpools for non‑therapeutic purposes) are not medically necessary.
Use of passive modalities beyond the acute phase without objective documentation of need is not supported. In general, passive modalities should transition to active therapeutic procedures early; the utilization of more than two passive modalities per visit is typically considered excessive and must be justified in the record.
Passive modalities should be used primarily during the acute phase or for short‑term symptom relief. Providers are expected to progress patients to active therapeutic procedures as swelling and acute symptoms subside and to document that transition in the medical record.
The policy specifies that the utilization of more than two passive modalities per office visit is typically excessive; continuation of passive modalities beyond approximately two weeks requires objective justification.
Active therapeutic procedures (therapeutic exercise, neuromuscular re‑education, therapeutic activities) should be initiated and advanced as clinically appropriate, with clear documentation of goals, frequency/duration, and measurable outcomes.
Routine use of Evaluation and Management (E/M) services as part of chiropractic manipulative therapy sessions is not medically necessary. An Established Patient E/M (reevaluation) may be appropriate only when there are new clinical findings, a rapid change in status, or failure to respond to treatment interventions.
The CMT service itself includes a brief reassessment and documentation of response to treatment; full E/M reevaluation components should be reserved for significant changes in condition that alter the plan of care.
Thermography performed using handheld contact methods is not medically necessary; only controlled‑condition infrared thermography may be considered for select diagnoses. Surface electromyography (SEMG) is considered experimental and investigational for diagnostic use and is not supported as a diagnostic billing service. Nonoperative spinal/paraspinal diagnostic ultrasound in adults is also considered investigational due to insufficient evidence of clinical utility.
The reference list in this section provides the literature citations that support the clinical statements and coverage positions in the guideline; the references section itself does not enumerate additional conditions deemed not medically necessary.
Coding
| 97010 | Application of a modality to 1 or more areas; hot or cold packs |
| 97012 | Application of a modality to 1 or more areas; traction, mechanical |
| 97014 | Application of a modality to 1 or more areas; electrical stimulation (unattended) |
| 97018 | Application of a modality to 1 or more areas; paraffin bath |
| 97022 | Application of a modality to 1 or more areas; whirlpool |
| 97024 | Application of a modality to 1 or more areas; diathermy (eg, microwave) |
| 97028 | Application of a modality to 1 or more areas; ultraviolet |
| 97032 | Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes |
| 97033 | Application of a modality to 1 or more areas; iontophoresis, each 15 minutes |
| 97034 | Application of a modality to 1 or more areas; contrast baths, each 15 minutes |
| 97016 | Application of a modality to 1 or more areas; vasopneumatic devices |
| 97026 | Application of a modality to 1 or more areas; infrared |
| 97169 | Athletic training evaluation, low complexity |
| 97170 | Athletic training evaluation, moderate complexity |
| 97171 | Athletic training evaluation, high complexity |
| 97172 | Re-evaluation of athletic training established plan of care |
| 97537 | Community/work reintegration training, each 15 minutes |
| 97545 | Assistive technology/device training, each 15 minutes |
| 97546 | Work hardening/conditioning; each additional hour |
| S8990 | Physical or manipulative therapy performed for maintenance rather than restoration |
| Atlas Orthogonal Technique | Listed as experimental/investigational (technique) |
| Dry Needling | Listed as experimental/investigational (procedure) |
| Elastic therapeutic tape/taping (e.g., Kinesio tape) | Listed as experimental/investigational |
| Vertebral axial decompression therapy and devices | Listed as experimental/investigational (device examples provided) |
| 97537 | Community/work reintegration training (example referenced) |
| 97545 | Assistive technology device/adaptive equipment (example referenced) |
| 97546 | Work hardening/conditioning; each additional hour |
| S8990 | Physical or manipulative therapy performed for maintenance rather than restoration |
| S9117 | Back school, per visit |
| 20560 | Needle insertion(s) without injection(s); 1 or 2 muscle(s) - listed as experimental/investigational |
| 20561 | Needle insertion(s) without injection(s); 3 or more muscles - experimental/investigational |
| 76499 | Unlisted diagnostic radiographic procedure - experimental/investigational when used for certain analyses |
| 76800 | Ultrasound, spinal canal and contents - experimental/investigational |
| S3900 | Surface electromyography (EMG) - experimental/investigational |
| S9090 | Vertebral axial decompression, per session - experimental/investigational |
| 97039 | Unlisted modality (specify type and time if constant attendance) - experimental/investigational when used to represent specified analyses |
| 97799 | Unlisted physical medicine/rehabilitation service or procedure - experimental/investigational when representing listed experimental treatments |
| No codes listed |
Provider Actions / Billing & Documentation
Use covered codes when requesting coverage
When coverage for chiropractic care exists under the benefit plan, submit services using the covered diagnosis and procedure codes listed in the Coding Information section; claims submitted for services not accompanied by covered code(s) under this policy will be denied as not covered.
- Use the appropriate covered CPT/HCPCS codes when requesting coverage.
- Services billed with codes not listed as covered in the Coding Information section are subject to denial.
Timed codes and CMT inclusion
A chiropractic treatment session may include CMT (CPT 98940–98943) and up to a maximum of four timed modality/procedure codes per date of service; a treatment session is defined as up to one hour and all services must be supported in the treatment plan.
Documentation affects authorization
Continued services and any authorization decisions depend on documentation that demonstrates objective functional progress through progress reports and appropriate use of reevaluation; the specific prior authorization effect is not detailed in these sections.
- Intermittent progress reports must document baseline and current functional status with objective measures tied to goals.
- Reevaluation (Established Patient E/M) is indicated only for new findings, rapid change, or failure to respond.
Investigational diagnostics may require review
Services identified as experimental or investigational (for example, SEMG for diagnostic purposes or nonoperative spinal/paraspinal diagnostic ultrasound) may not meet medical necessity and could require review or be denied if billed for diagnostic evaluation.
- Surface EMG (SEMG) is considered experimental and investigational for diagnostic purposes.
- Nonoperative spinal/paraspinal diagnostic ultrasound is considered investigational for adults.
Prior authorization
No prior authorization requirements are specified in the referenced sections of this policy.
- The document states that no prior authorization rules are provided in these reference sections.
Prior authorization not specified here
The referenced sections do not provide prior authorization rules or specify prior authorization processes for chiropractic services.
- No prior authorization rules are provided in this references section.
Not described in these chunks.
Certain items are not described in the referenced chunks of this section and therefore no provider action is specified here.
- Where the policy notes 'Not described in these chunks,' no additional provider action is mandated.
Passive-to-active transition and modality limits
Providers should transition from passive modalities to active therapeutic procedures early; use of passive modalities beyond the acute phase or use of more than two passive modalities per visit is typically not medically necessary and must be justified in the record.
- Passive modalities are generally most effective during the acute phase and decline after one to two weeks; ongoing use must be objectively justified.
- Utilization of more than two passive modalities per visit is typically excessive and should be justified in documentation.
Advanced exercise equipment use
MedX, Biodex, and Cybex equipment may be used as part of a multi‑modal program but evidence does not show superiority over other exercise forms; document the clinical rationale when selecting these devices over standard exercise.
- If using MedX/Biodex/Cybex, document why these devices are chosen instead of standard exercise approaches.
No step therapy rules are presented in t
No step therapy rules are presented in the referenced portions of this policy.
- The document explicitly states that no step therapy rules are presented in this references portion.
No step therapy requirements are given i
No step therapy requirements are given in the referenced sections of this policy.
- The references section does not provide step therapy requirements.
Required documentation elements
Daily treatment records and intermittent progress reports must include required elements: date of service, total treatment time, provider identity, specific CMT details (segments adjusted, thrust direction/technique), modality names and parameters, area of treatment, history/exam/MDM for evaluations, frequency/duration, measurable goals, prognosis; progress reports must also include start of care date, time period covered, functional baseline and current status, changes in plan/goals with rationale, consultations, and signature/title.
- Daily records: date, total treatment time, provider, treatments matching billed codes, modality parameters and timed service durations.
- Progress reports: start of care, time period covered, working diagnoses, objective measures tied to goals, changes in prognosis/plan/goals with rationale, consultations, signature and title.
Progress report documentation
Intermittent progress reports must document start of care date; time period covered; working diagnoses; baseline functional level and current status with objective functional measures tied to goals; changes in prognosis, plan of care, and goals with rationale; consultations/coordination; and signature and title of the qualified professional.
- Progress reports may be expanded treatment notes or formal reports and must demonstrate objective functional progress.
Reevaluation documentation
Reevaluation documentation should include objective measurements, assessment of intervention effectiveness, prioritized problem list, identification/modification of interventions, revisions to plan of care or discharge plan, and correlation to meaningful change in function.
- A formal reevaluation (Established Patient E/M) is indicated only for new clinical findings, rapid change, or failure to respond.
Prior imaging
If prior imaging exists from another facility, make reasonable attempts to obtain those prior studies before ordering further imaging.
- Obtain prior imaging when available to avoid unnecessary repeat studies.
This section contains bibliographic refe
This section of the policy contains bibliographic references supporting clinical statements and does not itself impose additional provider documentation requirements.
- References are provided for evidence context; they do not alter documentation or authorization requirements stated elsewhere in the policy.
This section lists literature citations
This portion of the policy lists literature citations used to support clinical statements; the reference list does not specify documentation requirements for claims or authorizations.
- See the References section for systematic reviews and other source citations.
Coding-based denial
Claims submitted for services that are not accompanied by covered code(s) under this policy will be denied as not covered.
- Ensure billed procedure and diagnosis codes match those listed as covered in the policy.
Visit length over limit
Treatment visits that extend beyond four timed unit services per date of service per provider (equivalent to one hour) are not covered or reimbursable and may be denied.
- Limit billed timed services to a maximum of 4 units per date of service per provider.
- Sessions exceeding 60 minutes are generally not demonstrated to have additional medical benefit.
Documentation and record-keeping risks
Failure to properly identify and sufficiently document therapy parameters, duplicated or cloned records, or insufficient record-keeping may result in adverse determinations (partial approval or denial).
- Avoid duplicated (cloned) records and ensure contemporaneous, individualized documentation.
- Document parameters for each therapy (e.g., modality settings, pad/electrode placement, time) on daily notes.
E/M billing limitations
Routine use of E/M services during CMT sessions is not medically necessary; billing E/M as a reevaluation is appropriate only when there are new clinical findings, rapid change in status, or failure to respond to treatment interventions.
- Do not routinely bill separate E/M for reevaluation during routine CMT treatment sessions.
Imaging clinical indication
Radiographic exams must have sufficient clinical indication and a reasonable anticipation that results will influence treatment; lack of clinical indication or use as screening may lead to denial.
- Obtain radiographs only when results are expected to affect treatment decisions and use the minimal radiation dose necessary.
- If prior imaging exists, attempt to obtain it before ordering new studies.
No authorization or denial instructions
No authorization or denial instructions are present in these reference lists.
- Reference sections list evidence citations and do not contain authorization or denial instructions.
No authorization or denial criteria are
No authorization or denial criteria are described in this references section.
- The references provide evidence context only and do not define authorization criteria.
Background
Chiropractic services are focused on diagnosis and treatment of musculoskeletal disorders and their effects on the nervous system and general health. Services should be individualized, delivered by qualified chiropractors, and integrated into an active, skilled plan of care with measurable, attainable goals.
Spinal manipulation (chiropractic adjustment) is a skilled therapeutic procedure intended to restore joint mobility by applying a controlled force to hypomobile joints to alleviate pain and improve function; it is appropriate when provided as part of a documented treatment plan aimed at functional improvement.
Definitions
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