ModifiedExcellus Health Plan IncPolicy 10.01.02

Chiropractic Care

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This policy governs medical necessity and coverage of chiropractic care for neuromusculoskeletal conditions when provided by a licensed Doctor of Chiropractic within the scope of licensure. It also identifies services that are not medically necessary or investigational and subjects all chiropractic care to retrospective utilization review.

Policy Summary

PayerExcellus Health Plan Inc

PolicyChiropractic Care

Policy CodePolicy 10.01.02

Change TypeModified

Effective DateOct 22, 2026

Next Review DateOct 1, 2027

Key ActionDocument the patient's history, examination, and diagnosis of a neuromusculoskeletal condition.

SourceLink

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ModifiedExcellus Health Plan IncPolicy 10.01.02

Chiropractic Care

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Policy Summary

PayerExcellus Health Plan Inc

PolicyChiropractic Care

Policy CodePolicy 10.01.02

Change TypeModified

Effective DateOct 22, 2026

Next Review DateOct 1, 2027

Key ActionDocument the patient's history, examination, and diagnosis of a neuromusculoskeletal condition.

SourceLink

POLICY UPDATE CHANGES

The policy history states that the not medically necessary maintenance care criteria were removed.

5Required medical-necessity criteria

100%Subject to retrospective utilization review

4Examples of contraindications identified

2Related medical policies

4CPT chiropractic procedure codes listed

Medical Necessity and Coverage Requirements

Medical Necessity for Chiropractic Care

Chiropractic care is medically appropriate when ALL of the following criteria are met.

ALL of the following

A documented history, examination, and diagnosis of a neuromusculoskeletal condition are present.
There is a reasonable expectation of recovery or improvement in function.
Treatment is provided in accordance with standards of generally accepted chiropractic practice.
Diagnostic procedures and therapeutic interventions are clearly related to the patient's symptoms or condition being treated.
The individualized treatment plan incorporates objective measures of patient-based outcomes.
Services are provided by a licensed Doctor of Chiropractic (DC), within the scope of the DC's state license.
Services are medically necessary and provided in connection with the detection or correction of spinal misalignment or mechanical/myofascial extremity pain.

Not Medically Necessary Chiropractic Uses

The following chiropractic uses are not medically necessary.

ANY of the following

Treatment intended to restore spinal curves.
Treatment of idiopathic scoliosis in an asymptomatic patient.

Investigational Nonneuromusculoskeletal Care

Chiropractic care is investigational when rendered for nonneuromusculoskeletal conditions.

Examples include

Infantile colic.
Childhood asthma.
Hypertension.
Primary dysmenorrhea.

New York Chiropractic Coverage Requirement

New York State law requires coverage for chiropractic care under specified comprehensive health coverage contracts.

Applicable statutory requirement

Contracts providing physician services, medical, major medical, or similar comprehensive-type coverage must include coverage for chiropractic care.
For purposes of New York coverage, chiropractic care means detecting and correcting structural imbalance, distortion, or subluxations in the human body through manual or mechanic means to remove nerve-interference effects related to distortion, misalignment, or subluxation of or in the vertebral column.

Product-Dependent Applicability

Medical policy criteria apply only according to the member's product benefits and any controlling external coverage criteria.

Services are contract dependent

If the member's product does not cover a service, medical policy criteria do not apply.
When the product covers the specific service, apply the following product-specific rule
- For a commercial product, including an Essential Plan or Child Health Plus product, medical policy criteria apply to the benefit.
- Medicaid product
  - The Medicaid product covers the specific service.
  - There are no applicable New York State Medicaid (eMedNY) guidelines or criteria.

Contraindications include, but are not limited to, recent compression fracture, severe osteoporosis, inflammatory arthropathy in the active systemic stage, local acute inflammation, infections, cauda equina syndrome, progressive or sudden neurological deficit, and visceral disease.

Treatment intended to restore spinal curves, or treatment of idiopathic scoliosis in an asymptomatic patient, is not medically necessary.

Routine or repeat x-rays to assess the function or structure of the spine are not medically necessary in the absence of red flags or clinical reasons to suspect serious underlying pathology.

Coding and Billing References

Code ModifierModifier

AT	Acute or active treatment; this modifier should be used when reporting service 98940, 98941, 98942.

Referenced Chiropractic ServicesCPT

98940	Service 98940; report with modifier AT for acute or active treatment.
98941	Service 98941; report with modifier AT for acute or active treatment.
98942	Service 98942; report with modifier AT for acute or active treatment.

CPT CodesCPTCovered

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
98943	Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions

HCPCS CodesHCPCS

N/A

ICD10 CodesICD-10

Multiple Codes

Code ModifierModifierCovered

AT	Acute or active treatment; this modifier should be used when reporting service 98940, 98941, 98942

Documentation and Utilization Review Requirements

Documentation Required

Document the clinical basis

Document the patient’s history, examination, and diagnosis of a neuromusculoskeletal condition before providing chiropractic care.

Documentation Required

Track individualized outcomes

Maintain an individualized treatment plan that incorporates objective measures of patient-based outcomes.

Documentation Required

Link services to the treated condition

Document that diagnostic procedures and therapeutic interventions are clearly related to the patient’s symptoms or condition being treated.

Policy Scope and Clinical Context

This policy addresses the diagnosis and management of neuromusculoskeletal conditions by a licensed Doctor of Chiropractic acting within the scope of state licensure. Covered care is limited to medically necessary services, including detection or correction of spinal misalignment and treatment of mechanical or myofascial extremity pain. Clinical documentation, medical necessity, and the relationship of services to the condition being treated support utilization review; all chiropractic care is subject to retrospective review, and services determined not medically necessary may be denied.

Terms and Clinical Definitions

Doctor of Chiropractic (DC)

ProviderA licensed Doctor of Chiropractic (DC).

ScopeProvides chiropractic care within the boundaries set by state licensure.

Clinical roleDiagnoses and manages neuromusculoskeletal conditions.

Covered chiropractic care

Service statusCare must be medically necessary.

Provider requirementServices must be provided by a licensed DC within the scope of the DC’s license.

Covered contextServices address detection or correction of spinal misalignment or mechanical/myofascial extremity pain.

Policy Summary

PayerExcellus Health Plan Inc

PolicyChiropractic Care

Policy CodePolicy 10.01.02

Change TypeModified

Effective DateOct 22, 2026

Next Review DateOct 1, 2027

Key ActionDocument the patient's history, examination, and diagnosis of a neuromusculoskeletal condition.

SourceLink

On This Page

Medical policy criteria apply to the benefit.

Medicare product, including a Medicare HMO-Dual Special Needs Program (DSNP) product

The Medicare product covers the specific service.
There is no applicable national or local Medicare coverage decision for the service.
Medical policy criteria apply to the benefit.

Medicare HMO-Dual Special Needs Program (DSNP) product does not cover the specific service

Refer to the Medicaid product coverage line.

Documentation Required

Follow accepted chiropractic standards

Document that treatment is provided in accordance with standards of generally accepted chiropractic practice.

Documentation Required

Establish expected functional benefit

Document a reasonable expectation of recovery or improvement in function as part of the medical-necessity record.

Denial Risk

Avoid noncovered spinal curve treatment

Treatment intended to restore spinal curves or treat idiopathic scoliosis in an asymptomatic patient is considered not medically necessary.

Denial Risk

Do not order routine repeat spinal x-rays

Routine or repeat x-rays used to assess spinal function or structure are not medically necessary when there are no red flags or clinical reasons to suspect serious underlying pathology.

Denial Risk

Limit care to neuromusculoskeletal conditions

Chiropractic care rendered for nonneuromusculoskeletal conditions is considered investigational and may not be covered.

Examples include infantile colic, childhood asthma, hypertension, and primary dysmenorrhea.

Denial Risk

Screen for contraindications and serious conditions

Services involving contraindicated clinical circumstances may be denied. Evaluate the patient for contraindications and serious clinical conditions before providing chiropractic care.

Recent compression fracture
Severe osteoporosis
Inflammatory arthropathy in the active systemic stage or acute local inflammation
Infections, cauda equina syndrome, progressive or sudden neurological deficit, or visceral disease

Denial Risk

Maintain records for retrospective review

All chiropractic care is subject to retrospective utilization review for determining medical necessity. Coverage for services determined to be not medically necessary will be denied.

Note

Verify product benefit coverage

Verify that the member’s product covers the service before relying on the medical policy criteria. If the product does not cover the service, medical policy criteria do not apply.

Red flags

MeaningClinical circumstances accompanying back pain and/or back pain with radiculopathy that may indicate a more serious underlying condition.

ExamplesHistory of cancer or unexplained weight loss.

Additional examplesImmunosuppression or urinary infection.

Chiropractic care

ProfessionA health care profession focused on disorders of the musculoskeletal system, primarily the spine, and the nervous system.

Conditions addressedNeuromusculoskeletal complaints include back pain, neck pain, pain in the joints of the arms or legs, and headaches.

ApproachUses a hands-on, drug-free approach involving patient examination, diagnosis, and treatment.

Additional careMay include therapeutic and rehabilitative exercises and nutritional, dietary, and lifestyle counseling.

Spinal manipulation

ProcedureA therapeutic procedure also referred to as a chiropractic adjustment.

TechniqueA controlled manual force is applied to a joint that has become hypomobile or restricted in movement.

PurposeRestores joint mobility and may alleviate pain and muscle tightness and restore function.

Red flags

MeaningClinical settings accompanying back pain and/or radiculopathy that may indicate a serious underlying condition.

ImmunosuppressionImmunosuppression accompanying back pain and/or radiculopathy is a red flag.

Neurologic concernGlobal or progressive motor weakness in the lower limbs is a red flag.

Chiropractic care under New York law

Legal requirementNew York contracts providing physician services, medical, major medical, or similar comprehensive-type coverage shall include coverage for chiropractic care.

Service descriptionChiropractic care detects and corrects structural imbalance, distortion, or subluxations in the human body.

Means and purposeThe correction may occur through manual or mechanical means to remove nerve-interference effects related to distortion, misalignment, or subluxation of or in the vertebral column.

NMN

AbbreviationNMN

MeaningNot medically necessary/appropriate.

Policy useThe abbreviation identifies services that are not medically necessary or appropriate.

E/I

AbbreviationE/I

MeaningExperimental/Investigational.

Policy useThe abbreviation identifies services classified as experimental or investigational.

AT modifier

ModifierAT

MeaningAcute or active treatment.

Reporting useUse the AT modifier when reporting CPT services 98940, 98941, and 98942.