CurrentColorado Rocky Mountain Health PlansPolicy 496

Medicare Chiropractic Services (Chiropractic Manipulative Treatment / CMT)

Defines Medicare-aligned medical necessity, documentation, and coding expectations for chiropractic manipulative treatment (CMT) for spinal subluxation and describes review processes for initial and ongoing care for Colorado Rocky Mountain Health Plans members under this policy.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMedicare Chiropractic Services (CMT)

Policy CodePolicy 496

Change TypeNo material changes

Effective DateFeb 11, 2026

Next Review Date

Key ActionDocument subluxation (x-ray or required physical exam findings) and provide a treatment plan with goals and objective measures for initial CMT; submit detailed documentation for review when requesting care beyond the initial course.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

98940-98942CPT codes listed for spinal CMT

CMS Chapter 15Medicare guidance referenced

InterQualInterQual referenced

Initial + ongoingDocumentation requirements

Coverage criteria for Chiropractic Manipulative Treatment (CMT)

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Medical necessity criteria for CMT

Covered when ALL of the following are met:

Medicare-aligned core criteria: The patient has a significant neuromusculoskeletal condition necessitating manipulative treatment that has a direct therapeutic relationship to the condition with a reasonable expectation of recovery or improved function; the primary diagnosis is subluxation of the spine demonstrated by x-ray or physical examination; the precise level of the subluxation is specified by the chiropractor; and manual manipulation of one or more spinal regions is planned.

Based on CMS Medicare Benefit Policy Manual Chapter 15 (see policy statement)

Physical exam demonstration of subluxation (if no x-ray): When subluxation is demonstrated by physical examination, require two of the following four findings, and one of the two must be asymmetry/misalignment or a range of motion abnormality: pain/tenderness (location, quality, intensity); asymmetry/misalignment identified on a sectional or segmental level; range of motion abnormality; tissue/tone changes in contiguous or associated soft tissues (skin, fascia, muscle, ligament).2 of 4 (one must be asymmetry/misalignment or ROM abnormality)

Applies when x-ray is not used to demonstrate subluxation

Initial course documentation: Documentation must include relevant personal and family health history; detailed present illness (symptoms related to the level of subluxation, quality/character, mechanism of trauma, onset, duration, intensity, frequency, location, radiation, aggravating/relieving factors); prior interventions; evaluation of the musculoskeletal/nervous system; a primary diagnosis naming subluxation and the level; and a treatment plan specifying recommended level of care (duration and frequency), specific treatment goals, objective outcome measures, and date of initial treatment.

Supports initial medical necessity determination

Care beyond initial course: Requests for care beyond the initial course must document review of the chief complaint and changes since last visit, focused examination of the involved spinal area with assessment of change, evaluation of treatment effectiveness, documentation of treatment performed on the date of visit, and planned treatment frequency, duration, and anticipated session length. Ongoing care is reviewed by an Optum clinical specialist and is subject to benefit restrictions and applicable mandates.

Used for prior authorization/review of continued care

Medicare limits chiropractic coverage to manual manipulation of the spine to correct a subluxation. All other services furnished or ordered by chiropractors are not covered under Medicare guidance (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30.5).

For this plan, chiropractic care (CMT) is covered only when Medicare-aligned medical necessity criteria are met: a significant neuromusculoskeletal condition requiring manipulation, a primary diagnosis of spinal subluxation demonstrated by x-ray or physical exam, the precise level of subluxation specified, and a plan for manual manipulation of one or more spinal regions.

Chiropractic manipulation provided for conditions that are not neuromusculoskeletal in nature is not medically necessary. The policy explicitly states chiropractic manipulation for non-neuromusculoskeletal conditions does not meet medical necessity under Medicare standards.

Maintenance therapy is defined as continuous, ongoing chiropractic care that is supportive rather than corrective when further clinical improvement cannot reasonably be expected. Under Medicare rules, such maintenance therapy is not considered medically reasonable or necessary and therefore is not covered.

Provider actions, documentation, and utilization review

Documentation Required

Initial course documentation requirements

Initial course requests must document a demonstrable subluxation and a complete evaluation and plan. A subluxation must be shown on x‑ray or by physical exam. If by physical exam, at least two of the following four findings are required and one must be asymmetry/misalignment or a range of motion abnormality: pain/tenderness (location, quality, intensity), asymmetry/misalignment at a sectional or segmental level, range of motion abnormality, or tissue/tone changes of contiguous soft tissues (skin, fascia, muscle, ligament). Additional required documentation (whether x‑ray or physical exam demonstrates the subluxation) includes relevant personal and family history; a focused description of the present illness (symptoms directly related to the level of subluxation, quality/character of symptoms, mechanism of trauma, onset/duration/intensity/frequency/location/radiation, aggravating/relieving factors, prior interventions/treatments/medications, secondary complaints); a musculoskeletal/neurologic physical examination; a primary diagnosis of subluxation with the level specified (either naming the spinal joint involved or the positional/directional description of the bone); and a treatment plan that specifies recommended level of care (duration and frequency), specific treatment goals, objective measures to evaluate effectiveness, and the date of initial treatment.

Subluxation demonstration: x‑ray OR physical exam (>=2 of 4 findings; one must be asymmetry/misalignment or ROM abnormality)
Required history and exam: relevant personal/family history; focused present illness (mechanism, onset, duration, intensity, frequency, location, radiation); prior interventions; musculoskeletal/neurologic exam
Diagnosis: primary diagnosis must be subluxation with level specified
Treatment plan: level of care, duration/frequency, specific goals, objective outcome measures, date of initial treatment

Documentation Required

Ongoing care documentation requirements

Requests for care beyond the initial course must clearly document ongoing medical necessity and reasonableness. Documentation should include a review of the chief complaint and any changes since the last visit (including system review if relevant); a focused spinal/area examination documenting assessment of change in condition and evaluation of treatment effectiveness; documentation of treatments provided during the visit; and the proposed treatment frequency, session duration, and anticipated total length of further care. All requests for continuation of care are reviewed by an Optum clinical specialist and are subject to benefit limits, state/federal mandates, and the provider’s documentation demonstrating medical necessity and reasonableness.

History: review of chief complaint; changes since last visit; system review if relevant
Exam: focused examination of involved spinal area; assessment of change since prior visit; evaluation of treatment effectiveness
Visit-level documentation: treatment given on the day of visit
Plan: treatment frequency, anticipated length and duration of sessions
Review process: all ongoing care reviewed by an Optum clinical specialist; determinations subject to benefit restrictions and regulations

Note

Use of InterQual for appropriateness/dosage

InterQual® Outpatient Rehabilitation & Chiropractic criteria are used to determine the appropriateness and recommended dosage (frequency and duration) for outpatient rehabilitation and chiropractic services. These evidence‑based criteria supplement general Medicare provisions to ensure consistent, clinically supported decisions about whether requested services and requested quantities are reasonable and necessary. Use of InterQual helps identify when care is indicated, when care is contraindicated, and supports dosing/continuation decisions based on documented clinical findings and measurable outcomes.

InterQual® Outpatient Rehabilitation & Chiropractic Criteria applied to appropriateness and dosage decisions
Criteria inform approval/denial and recommended frequency/duration based on documented clinical findings and outcomes
Incomplete or poor documentation may lead to inappropriate denials under InterQual review

Key definitions

Subluxation — definition

DefinitionA motion segment in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact; a subluxation may be demonstrated on x-ray or physical examination.

DemonstrationMay be demonstrated by x-ray or by physical examination (acute condition when treated for a new injury as determined by x-ray or physical exam).

Clinical relevanceIdentifies the primary diagnosis required for Medicare-aligned coverage of chiropractic manipulative treatment (CMT).

Manual manipulation / CMT — definition

DefinitionChiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function accomplished using a variety of techniques.

Expected effectThe result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient’s condition.

ScopeManual manipulation refers specifically to techniques applied to spinal motion segments to produce therapeutic changes in function and alignment.

98940	Chiropractic manipulative treatment (CMT); spinal, 1-2 regions.
98941	Chiropractic manipulative treatment (CMT); spinal, 3-4 regions.
98942	Chiropractic manipulative treatment (CMT); spinal, 5 regions.

OpenPayer

Medicare Chiropractic Services (Chiropractic Manipulative Treatment / CMT)

Coverage criteria for Chiropractic Manipulative Treatment (CMT)

Procedure codes for CMT

Provider actions, documentation, and utilization review

Background and scope

Key definitions