ModifiedColorado Rocky Mountain Health PlansPolicy MMP227.13

Osteopathic Manipulations (OMT)

Defines coverage, coding, limitations, and clinical context for osteopathic manipulative treatment (OMT) provided primarily by osteopathic physicians; affects providers submitting claims to Colorado Rocky Mountain Health Plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOsteopathic Manipulations (OMT)

Policy CodePolicy MMP227.13

Change TypeClinical evidence & references updatededitorial link added

Effective DateMay 1, 2026

Next Review Date

Key ActionDocument somatic dysfunction (TART findings) in the medical record to support coverage and claims for OMT.

SourceLink

POLICY UPDATE CHANGES

Added reference link to the UnitedHealthcare Medicare Advantage Reimbursement Policy titled Global Days Policy, Professional.

Updated Clinical Evidence and References sections to reflect the most current information.

5OMT procedure codes listed

10Diagnosis codes listed

MultipleEvidence references (2023-2025)

AbsentMedicare NCD

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Policy revision date

Coverage Criteria for OMT

Coverage criteria

Covered when ALL of the following are met

Documentation: Conventional documentation of somatic dysfunction (e.g., TART: tissue texture change, asymmetry, restriction of motion, tenderness) is present in the medical record.

Absence of such documentation results in noncoverage; retain records to support claims.

Separate services: Evaluation and management (E&M) services are covered only when medically necessary and separately documented; routine follow-up OMT visits do not warrant a separate E&M unless a new condition or substantial change necessitates reassessment.

Document justification for any billed E&M per plan guidance.

Summary of clinical evidence and guideline statements

Evidence-based statements and guideline recommendations summarized from systematic reviews, meta-analyses, RCTs, and clinical practice guidelines

Chronic neck pain - manipulative therapy: Systematic review/meta-analysis (Liu et al. 2023) showed manipulative therapy significantly decreased pain intensity and neck disability versus exercise/control for chronic neck pain (>3 months), though heterogeneity and variable study quality were noted.

See pooled outcomes for NPRS/VAS and NDI.

Upper cross syndrome and postural dysfunction: Physiotherapeutic interventions including manual therapy (e.g., myofascial release, muscle energy) produced short-term improvements in postural variables and pain/function when advanced manual techniques were used (Chaudhuri et al. 2023).

Effects often short-term; study risk of bias varied.

Mobilization with movement for shoulder disorders: MWM added to exercise/electrotherapy was associated with clinically meaningful improvements in pain, flexion and abduction ROM, and disability for frozen shoulder and movement-related shoulder pain, although many trials had high risk of bias (Satpute et al. 2022).

Interpret results cautiously due to methodological limitations.

OMT for low back and chronic pain: Overviews and RCTs suggest OMT may reduce pain and improve function in non-specific low back pain and other musculoskeletal conditions, but overall evidence quality ranges from low to very low and heterogeneity is common (Bagagiolo et al. 2022; Dal Farra et al. 2021/2022; Nguyen et al. 2021; Zhou et al. 2022).

Benefits observed across several small trials and some larger RCTs, but limitations include risk of bias and variable follow-up.

Specific RCTs showing benefit when combined with exercise or versus sham: Individual RCTs reported greater pain and function improvement when OMT or manual techniques were combined with exercise versus exercise alone (Groisman et al. 2020) and small benefits versus sham in LBP trials (Nguyen et al. 2021), though sample sizes and blinding limitations temper conclusions.

Consider trial-level limitations (sample size, loss to follow-up).

Postoperative and other contexts: Systematic reviews of postoperative TKA and other settings reported potential benefits of OMT for range of motion, edema, pain control, and earlier return to ADLs, but evidence is limited and heterogeneous (Zhou et al. 2022).

Further randomized, long-term studies needed.

Postural outcomes evidence: Meta-analysis of manual therapy for postural change (Santos et al. 2022) showed short/medium-term improvements in forward head posture, thoracic kyphosis, and pelvic alignment but no consistent effects for shoulder protrusion, frontal-plane shoulder alignment, or scoliosis.

Certainty of evidence varied from low to moderate.

Clinical guideline position for low back pain: ACP/APS clinical practice guidelines recommend nonpharmacologic treatments including manipulative therapy as first-line for acute, subacute, and chronic low back pain and spinal manipulation for patients not improving with self-care.

Guideline support influences recommended sequencing of nonpharmacologic care.

Coverage conditions for OMT

Covered when ALL of the following are met

Documentation of somatic dysfunction: Somatic dysfunction is documented in the history and/or physical examination (identified by one or more elements of TART).

AOA guidance requires documentation; absence makes OMT not payable.

Claims and prior authorization compliance: Claims submission and any delegated prior authorization requirements follow plan or delegate instructions and retainers of appropriate documentation are available upon request.

Providers are responsible for accurate claims submission and must follow delegate prior authorization rules for Medicare Advantage when applicable.

OMT is not covered when the clinical indication criteria are not met and conventional documentation of somatic dysfunction (for example, TART findings) is absent from the patient's medical record. Lack of such documentation is an explicit trigger for noncoverage.

Systematic reviews and meta-analyses found that manual therapy techniques can improve certain postural measures (e.g., forward head posture, thoracic kyphosis, pelvic alignment) in the short to medium term, but manual therapy was not superior to other interventions for shoulder protrusion, shoulder alignment in the frontal plane, scoliosis, and some other postural outcomes; certainty of evidence ranged from moderate to very low.

OMT is not payable when somatic dysfunction is not documented in the patient's history or physical examination; documentation of somatic dysfunction in the medical record is a condition of payment.

A separate E&M service is not warranted for previously planned follow‑up OMT treatments unless a new condition arises or the patient's condition has changed substantially and requires overall reassessment.

The overall body of evidence for many OMT indications is limited or inconclusive. Systematic reviews report promising signals for musculoskeletal disorders but note low or very low quality, small samples, high heterogeneity, and conflicting results for several conditions (including pediatric conditions, primary headache, and IBS), which limits definitive conclusions about relative efficacy and safety.

Procedure and Diagnosis Codes

Covered CPT Codes (listed for reference)CPT

98925	Osteopathic manipulative treatment (OMT); 1-2 body regions involved.
98926	Osteopathic manipulative treatment (OMT); 3-4 body regions involved.
98927	Osteopathic manipulative treatment (OMT); 5-6 body regions involved.
98928	Osteopathic manipulative treatment (OMT); 7-8 body regions involved.
98929	Osteopathic manipulative treatment (OMT); 9-10 body regions involved.

Relevant ICD-10 Diagnosis CodesICD-10

M99.00	Segmental and somatic dysfunction of head region.
M99.01	Segmental and somatic dysfunction of cervical region.
M99.02	Segmental and somatic dysfunction of thoracic region.
M99.03	Segmental and somatic dysfunction of lumbar region.
M99.04	Segmental and somatic dysfunction of sacral region.
M99.05	Segmental and somatic dysfunction of pelvic region.
M99.06	Segmental and somatic dysfunction of lower extremity.
M99.07	Segmental and somatic dysfunction of upper extremity.
M99.08	Segmental and somatic dysfunction of rib cage.
M99.09	Segmental and somatic dysfunction of abdomen and other regions.

Provider Billing, Documentation, and Authorization Actions

Prior Authorization

Procedure codes — verify prior authorization per plan

Verify whether prior authorization is required for the listed OMT procedure codes before scheduling or billing. Benefit coverage is determined by the member-specific plan; confirm authorization rules with the payer or the delegate managing utilization for the member's Medicare Advantage plan.

Affected CPT codes: 98925–98929 (OMT, 1–10 body regions).
Confirm member-specific benefit coverage and prior authorization requirements via payer portal or customer service (number on member ID card).

Note

Prior authorization absence in clinical evidence section

The clinical evidence section of this policy describes guideline recommendations supporting nonpharmacologic therapies (including manipulative/manual therapy) for low back pain. However, this policy does not substitute for payer-specific prior authorization pathways; absence of a prior authorization statement in the clinical evidence does not imply authorization is unnecessary. Follow plan-specific prior authorization rules.

Background on OMT

Osteopathic manipulative treatment (OMT) comprises hands‑on techniques performed by DOs or MDs to address somatic dysfunction — an impaired or altered function of skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements. Somatic dysfunction is identified by elements of TART (tissue texture changes, asymmetry/positional findings, range of motion alterations, tenderness) and may affect multiple regions; OMT techniques (for example, muscle energy, HVLA, counterstrain, myofascial release) are selected based on patient age and clinical presentation to improve pain, function, and range of motion.

Key Definitions and Terminology

Somatic dysfunction / TART — definition and components

DefinitionSomatic dysfunction: impaired or altered function of components of the somatic (body‑framework) system — skeletal, arthroidal, and myofascial structures and related vascular, lymphatic, and neural elements.

TART acronymTenderness; Asymmetry (positional/asymmetry); Restriction of motion (range of motion alterations); Tissue abnormality (tissue texture changes or palpatory sensitivity).

Positional/motion parametersDescribe at least one of: (1) position by palpation relative to adjacent structure, (2) direction in which motion is freer, (3) direction in which motion is restricted.

Clinical implicationSomatic dysfunction in one region may produce compensatory dysfunction in other regions and can include a somatic component of visceral disease.

Glossary of Osteopathic Terminology — standardized glossary reference (ECOP/AACOM)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOsteopathic Manipulations (OMT)

Policy CodePolicy MMP227.13

Change TypeClinical evidence & references updatededitorial link added

Effective DateMay 1, 2026

Next Review Date

Key ActionDocument somatic dysfunction (TART findings) in the medical record to support coverage and claims for OMT.

SourceLink

On This Page

Documentation Required

Required clinical documentation

Document somatic dysfunction in the medical record to support OMT billing and payment. Records should include relevant history and physical exam findings (TART: tissue texture change, asymmetry/position, restriction of motion/range, tenderness) and the clinical rationale for OMT. Retain and produce records upon request.

TART findings (Tenderness, Asymmetry, Restriction of motion, Tissue texture change) must be present in history and/or physical exam.
If somatic dysfunction is not documented, OMT is not payable.
Retain documentation of treatment plan, number of body regions treated, and clinical response.

Documentation Required

Outcome measurement expectations

Measure and document outcomes using standardized pain and function scales where appropriate to support medical necessity and monitor response to OMT. Use the same or similar validated instruments referenced in clinical trials and guidelines to track progress.

Recommended instruments: NPRS/VAS, Numeric Pain Rating Scale; NDI (Neck Disability Index); ODI (Oswestry Disability Index); RMDQ (Roland-Morris); WOMAC where applicable.
Record baseline and follow-up scores and clinical interpretation showing improvement, stability, or need for continued care.

Step Therapy

Step therapy — guideline context

Consider guideline-recommended sequencing when planning OMT as part of care. Clinical guidelines endorse nonpharmacologic therapies, including manipulative/manual therapy, as first-line or as part of a treatment package for low back pain and other musculoskeletal conditions; document prior conservative care or rationale for earlier use of OMT when applicable.

ACP/APS: nonpharmacologic treatments including manipulation recommended as first-line for acute, subacute, and chronic LBP.
NICE: manual therapy recommended only as part of a package including exercise and, if used, document exercise/rehabilitation component.
If plan has step therapy requirements, follow the plan's step sequence and document prior self-care or conservative treatments tried and their outcomes.

SourceGlossary of Osteopathic Terminology developed and revised by the Educational Council on Osteopathic Principles (ECOP) of AACOM (American Association of Colleges of Osteopathic Medicine).

PurposePresents important terms unique to osteopathic practice to standardize terminology across the profession.

ScopeIncludes definitions uniquely osteopathic in origin or usage and terms important to Osteopathic Principles and Practice (OPP)/OMT.

Osteopathic manipulative treatment (OMT) — definition of hands-on techniques and targets

DefinitionOsteopathic manipulative treatment (OMT): hands‑on techniques performed by osteopathic physicians to address somatic dysfunction and improve pain, function, and range of motion.

Techniques includedMuscle energy, high‑velocity low‑amplitude (HVLA), counterstrain, myofascial release, visceral manipulation, craniosacral techniques (choice varies by patient age and condition).

Intended targetsSkeletal, arthroidal, myofascial structures and related vascular/lymphatic/neural elements to restore physiologic function and support homeostasis.

Mobilization with movement (MWM) — definition and common applications

DefinitionMobilization with movement (MWM): a manual therapy applied to joints (commonly the shoulder) often performed in conjunction with active movement or exercise to restore joint mechanics and reduce pain.

Common applicationsUsed for frozen shoulder and shoulder pain with movement dysfunction to improve pain, flexion and abduction range of motion, and disability when added to exercise/electrotherapy.

Evidence noteMeta‑analyses show clinically meaningful short‑term improvements in pain, ROM, and function, though many studies have methodological limitations and limited long‑term data.

Myofascial release (MFR) — definition and common adjunctive use

DefinitionMyofascial release (MFR): a manual technique applying sustained pressure to restricted fascia to relieve pain and restore movement, frequently combined with stretching exercises.

Adjunctive useOften used alongside stretching, muscular energy, or exercise; reported benefits in postural syndromes and chronic low back pain studies with moderate evidence for pain reduction.

Evidence noteSystematic reviews report MFR as more effective than control treatments for decreasing pain and improving function in some musculoskeletal conditions, though study quality varies.

Osteopathic manipulative treatment (OMT) — therapeutic application by osteopathic physicians to improve physiologic function

AOA/AACOM definitionOMT is 'the therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis altered by somatic dysfunction.'

Clinical requirement for paymentAOA guidance: OMT is payable when somatic dysfunction is documented in the history and/or physical examination; not payable if somatic dysfunction is not documented.

Scope of useOMT may be used to treat somatic components of visceral disease and any organ system manifesting changes in skeletal, arthrodial, or myofascial tissues.