CurrentAmeriHealth Caritas LouisianaPolicy ILO.02

Chiropractic Services for Adults ACLA

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Coverage for adult Louisiana Medicaid enrollees receiving chiropractic diagnosis and treatment for neuromusculoskeletal conditions associated with spinal functional integrity, when provided as a medically appropriate and cost-effective In Lieu Of alternative.

Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyChiropractic Services for Adults ACLA

Policy CodePolicy ILO.02

Change TypeNo material clinical or coverage change

Effective DateFebruary 1, 2023

Last ReviewJul 1, 2025

Next Review DateJune 1, 2027

Key ActionMaintain an individualized treatment plan supporting the applicable symptom-intensity category, treatment duration, session count, and service-specific units.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

300Annual enrollment cap

2Additional treatment categories per day

6 sessions/18 weeks

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CurrentAmeriHealth Caritas LouisianaPolicy ILO.02

Chiropractic Services for Adults ACLA

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Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyChiropractic Services for Adults ACLA

Policy CodePolicy ILO.02

Change TypeNo material clinical or coverage change

Effective DateFebruary 1, 2023

Last ReviewJul 1, 2025

Next Review DateJune 1, 2027

Key ActionMaintain an individualized treatment plan supporting the applicable symptom-intensity category, treatment duration, session count, and service-specific units.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

300Annual enrollment cap

2Additional treatment categories per day

6 sessions/18 weeks

Covered Chiropractic Services

Covered adult chiropractic care

Covered when the member meets the stated clinical condition and the service is provided as an In Lieu Of alternative.

Covered chiropractic services: The member is an adult enrollee and is diagnosed with a neuromusculoskeletal condition associated with the functional integrity of the spine; the chiropractic service is used to diagnose or treat that condition; and the service is provided as a medically appropriate and cost-effective substitute for an applicable Louisiana Medicaid State Plan service or setting.

The service is available at the enrollee's option as an In Lieu Of alternative.

Symptom-intensity treatment limits

Treatment units vary according to individualized treatment plans and symptom intensity.

Symptom-intensity treatment categories

Mild-to-moderate: Use 1x99203 + 5x99213 for evaluation and management, 1x72100 for spinal X-ray, 6x98941 for spinal manipulation, and 3x97124 for other treatment.6 treatment sessions over an 18-week period
Moderate-to-severe: Use 1x99203 + 11x99213 for evaluation and management, 1x72110 for spinal X-ray, 6x98941 + 6x98942 for spinal manipulation, and 12x97124 + 6x20560 for other treatments.12 treatment sessions over a 26-week period
Severe: Use 1x99203 + 17x99213 for evaluation and management, 1x72110 for spinal X-ray, 18x98942 for spinal manipulation, and 18x97140 + 18x20561 for other treatments.18 treatment sessions over a 12-month period

The policy covers a maximum of two other treatments per day of service in addition to spinal manipulation. More than two other treatments on the same day are outside the stated covered daily maximum.

Covered Services and Limits

Covered CPT CodesCPTCovered

99202	Office or other outpatient visit for the evaluation and management of a new patient
99203	Office or other outpatient visit for the evaluation and management of a new patient
99204	Office or other outpatient visit for the evaluation and management of a new patient
99205	Office or other outpatient visit for the evaluation and management of a new patient
99212	Office or other outpatient visit for the evaluation and management of an established patient
99213	Office or other outpatient visit for the evaluation and management of an established patient
99214	Office or other outpatient visit for the evaluation and management of an established patient
99215	Office or other outpatient visit for the evaluation and management of an established patient

Covered CPT CodesCPTCovered

72020	Radiologic examination, spine, single view, specify level
72040	Radiologic examination, spine, cervical; 2 or 3 views
72050	Radiologic examination, spine, cervical; 4 or 5 views
72052	Radiologic examination, spine, cervical; 6 or more views
72070	Radiologic examination, spine, thoracic, 2 views
72072	Radiologic examination, spine, thoracic, 3 views
72074	Radiologic examination, spine, thoracic, minimum of 4 views
72080	Radiologic examination, spine, thoracolumbar, 2 views
72100	Radiologic examination, spine, lumbosacral; 2 or 3 views
72110	Radiologic examination, spine, lumbosacral; minimum of 4 views

1–10 of 13

1/2

Covered CPT CodesCPTCovered

98940	Spinal manipulation, 1-2 regions
98941	Spinal manipulation, 3-4 regions
98942	Spinal manipulation, 5 regions

Covered CPT CodesCPTCovered

97012	Mechanical traction
97022	Whirlpool therapy
97035	Ultrasound therapy
97032	Electrical stimulation
97110	Therapeutic exercises
97112	Neuromuscular reeducation
97116	Gait training
97124	Massage therapy
97140	Manual therapy
20560	Needle insertion without injection, 1-2 muscles

1–10 of 11

1/2

Other treatments per day

Daily limitMaximum of 2 other treatments per day of service

Additional treatment relationshipThe limit applies to treatments provided in addition to spinal manipulation

Included servicesTreatment CPT codes listed in the unit-of-service table but not in the symptom-intensity table are included in this daily maximum

Annual enrollment cap

Annual cap300 total enrollees per year

ProgramAdult Chiropractic Care

Provider Documentation and Program Requirements

Documentation Required

Individualized Treatment Plan Documentation

Document an individualized treatment plan that identifies the member’s symptom-intensity category and the anticipated treatment duration. Align the planned services and units with the applicable category: Mild-to-Moderate—six sessions over 18 weeks; Moderate-to-Severe—12 sessions over 26 weeks; Severe—18 sessions over 12 months.

Mild-to-Moderate: 1x99203 + 5x99213; 1x72100; 6x98941; 3x97124.
Moderate-to-Severe: 1x99203 + 11x99213; 1x72110; 6x98941 + 6x98942; 12x97124 + 6x20560.
Severe: 1x99203 + 17x99213; 1x72110; 18x98942; 18x97140 + 18x20561.

Documentation Required

Utilization Reporting and Case Management

Submit or maintain utilization reporting to support monitoring of program activities. Reports may be requested for member profiles, provider information, and case-management referrals; coordinate with Case Management and participate in case rounds when appropriate.

Identify and refer members who may benefit from care coordination or case-management services, particularly complex members with multiple chronic diseases and high Emergency Room or Inpatient utilization.

Policy Background and Scope

This policy addresses chiropractic services for adult AmeriHealth Caritas Louisiana Medicaid enrollees. It covers chiropractic diagnosis and treatment of neuromusculoskeletal conditions associated with the functional integrity of the spine when the service is medically appropriate and cost-effective as an alternative to applicable Louisiana Medicaid State Plan services or service limits. The program is intended to expand pain-treatment alternatives and support improved pain-management prescribing behavior.