ModifiedMass General Brigham Health PlanPolicy 013

Medical Necessity Guidelines Chiropractic Services

Medical necessity guidelines for chiropractic services (evaluation, diagnosis, treatment, and supportive therapies) across Mass General Brigham Health Plan products; describes authorization, coverage criteria, exclusions, and coding information that affect providers and members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines Chiropractic Services

Policy CodePolicy 013

Change TypeOperational updatesexclusions addedInterQual customization clarified

Effective DateNov 1, 2016

Next Review DateApr 1, 2026

Key ActionObtain prior authorization when required by product rules (for example, Medicare Advantage for visits 21+ and MassHealth when visit limits or age rules apply).

SourceLink

POLICY UPDATE CHANGES

Updated prior authorization information and added variation for One Care and SCO members.

Added exclusion for Maintenance Therapy.

InterQual® customization described and criteria hierarchy clarified for One Care and SCO.

20MassHealth visit limit per benefit year

Visits 21+Medicare Advantage prior auth

0-24 moNot covered age (Commercial & QHP)

InterQual®

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Primary criteria source

Coverage and Medical Necessity Criteria

Medical necessity (general)

Covered chiropractic services for treatment of neuromuscular and/or musculoskeletal conditions when InterQual® criteria (customized) are met.

Base coverage: Services are for medically necessary examination, evaluation, diagnosis, or treatment of neuromuscular and/or musculoskeletal illnesses, injuries, conditions, or disorders; includes chiropractic adjustments/manipulations and supportive procedures/therapies.

Determination of medical necessity is made using InterQual® criteria as customized by Mass General Brigham Health Plan. Access InterQual® via the provider website.

Chiropractic services are not covered for Commercial and Qualified Health Plan members aged 0 to 24 months. Claims billed for members in this age range will be denied per the policy exclusion. In addition, services directed at a condition that is not improving or resolving are excluded from coverage.

Systematic reviews cited in the contract identify documented adverse events associated with pediatric spinal manipulation, and these findings inform policy decisions about when pediatric manipulative interventions should be excluded or restricted. When considering care for infants and young children, clinicians and facilities should apply these safety considerations and follow the explicit age-based exclusion for Commercial and Qualified Health Plan members 0 to 24 months described elsewhere in this policy.

Maintenance therapy — defined as ongoing care intended to prevent deterioration or promote health when further clinical improvement cannot reasonably be expected — is considered not medically necessary. When treatment becomes supportive rather than corrective in nature and additional clinical improvement is unlikely, continued chiropractic visits for maintenance purposes are excluded from coverage.

Supportive procedures and therapies provided in the course of chiropractic care (for example, traction, thermal modalities, ultrasound, electrical modalities, hydrotherapy, myotherapy, braces, or rehabilitative exercise) do not change this determination: if the overall plan is maintenance in intent, those services are also not covered under this policy.

Billing and Coding

Codes listed in policymixed

97010	Application of a modality to one 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).
97016	Application of a modality to 1 or more areas; vasopneumatic devices.
97018	Application of a modality to one or more areas; paraffin bath.
97022	Application of a modality to one or more areas; whirlpool.
97024	Diathermy (e.g. microwave).
97026	Infrared.
97028	Application of a modality to one or more areas; ultraviolet.
97032	Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes.

1–10 of 31

1/4

MassHealth visit limit

MassHealth visit limit20 visits per benefit year

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization requirements vary by product and contract. For Medicare Advantage members, visits 1-20 do not require prior authorization but visits 21+ require prior authorization. Mass General Brigham Health Plan follows CMS guidance (NCDs, LCDs, LCAs, and Medicare manuals) for Medicare Advantage medical necessity determinations; when CMS guidance is absent, the plan's medical policies apply. For Mass General Brigham ACO members, MassHealth guidance applies and MassHealth limits chiropractic services to 20 visits per benefit year; visits beyond 20 are not covered. For Commercial and Qualified Health Plans, prior authorization may be required — refer to specific plan materials for visit limits and triggers (examples: City of Boston Value HMO: prior auth after 12th visit; Town of Auburn plans: prior auth after 20th visit; Complete HMO for GIC Members: prior auth for members under age 13).

Medicare Advantage: Prior authorization required for visits 21+; CMS NCD/LCD/LCA/Medicare Manual guidance is primary.
Mass General Brigham ACO / MassHealth: MassHealth limits chiropractic services to 20 visits per benefit year; visits beyond 20 will not be covered.
Commercial & Qualified Health Plans: Prior authorization may be required per plan — check plan materials (City of Boston Value HMO, Town of Auburn, Complete HMO for GIC Members).

Background

Chiropractic services encompass manual techniques performed by a licensed chiropractor to manipulate, mobilize, adjust, stimulate, or otherwise influence synovial joints and paraspinal tissues of the spinal column. The primary clinical goal is to restore joint mobility by applying a controlled force to joints that have become hypomobile or restricted following tissue injury.

The policy distinguishes primary chiropractic manipulative treatment (the correction of misalignments, subluxations, or segmental joint dysfunction of the vertebral column, pelvis, and adjacent areas) from supportive procedures and therapies. Supportive treatments — which may include traction, thermal modalities, ultrasound, electrical modalities, hydrotherapy, myotherapy, bracing, and rehabilitative exercise — are intended to assist the chiropractor in achieving a timely and favorable clinical outcome but are complementary to the primary manipulative techniques.

Definitions

Chiropractic Services (manual techniques)

DefinitionManual techniques where the hands are used to manipulate, mobilize, adjust, stimulate, or otherwise influence synovial joints and paraspinal tissues in the spinal column to restore joint mobility and function.

IncludesChiropractic manipulative treatment addressing misalignments, subluxations, or segmental joint dysfunction of the vertebral column, pelvis, and adjacent areas.

PurposeTo restore joint mobility by applying a controlled force into hypomobile or restricted joints resulting from tissue injury.

Maintenance Therapy

DefinitionOngoing care intended to prevent deterioration or promote health when further clinical improvement cannot reasonably be expected; care that becomes supportive rather than corrective is considered maintenance therapy.

Policy stance

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines Chiropractic Services

Policy CodePolicy 013

Change TypeOperational updatesexclusions addedInterQual customization clarified

Effective DateNov 1, 2016

Next Review DateApr 1, 2026

Key ActionObtain prior authorization when required by product rules (for example, Medicare Advantage for visits 21+ and MassHealth when visit limits or age rules apply).

SourceLink

On This Page

Documentation Required

Clinical Documentation and Criteria Source

Medical necessity determinations and clinical criteria sources must be documented. For Medicare Advantage determinations, Mass General Brigham Health Plan uses CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and Medicare manuals (e.g., Medicare Benefit Policy Manual, Chapter 15, section 240.1 and related LCDs L37254, L37387). When CMS guidance is not available or lacks specificity, Mass General Brigham Health Plan applies its medical policies and customized InterQual® criteria to ensure consistent review.

CMS sources: NCDs, LCDs, LCAs, Medicare manuals (Medicare Benefit Policy Manual, Ch.15 §240.1; LCA A57889; LCDs L37254, L37387).
Plan sources: Mass General Brigham Health Plan medical policies and customized InterQual® criteria (access via provider website Resources > InterQual® Criteria Lookup).

Documentation Required

Supporting Documentation

Supporting clinical documentation and evidence must be available to substantiate medical necessity requests. Reviewers may request references, clinical notes, prior treatment history, and relevant literature to support the requested services. Mass General Brigham Health Plan aligns coverage criteria with current clinical evidence and accepted standards of practice and may apply additional criteria where federal or state guidance lacks specificity.

Provide clinical notes, treatment response, and rationale for continued therapy when requesting authorization beyond routine visit limits.
Be prepared to supply peer-reviewed references or guidelines cited in the policy or relevant literature when requested by the plan.

Note

State Regulatory Compliance and Contract Determination

State and contract regulatory requirements affect authorization and coverage rules. Commonwealth of Massachusetts regulations (130 CMR 441.000) and any applicable EOHHS ACPP contract provisions govern coverage parameters for MassHealth/ACO members. Prior authorization requirements and visit limits are determined per payer contract and plan-specific materials; always verify contract terms (e.g., EOHHS ACPP Contract) when submitting requests.

Commonwealth of Massachusetts: 130 CMR 441.000 (Chiropractor Services) applies to MassHealth/ACO determinations.
Contract terms (EOHHS ACPP Contract) and plan materials dictate prior authorization triggers and limits; follow the specific contract for members covered under those agreements.

Denial Risk

Provider Billing and Action Items

Provider billing and clinical action items to avoid denials: ensure age-based exclusions and maintenance therapy rules are observed, and follow plan-specific prior authorization triggers.

Do not bill chiropractic services for Commercial and Qualified Health Plan members aged 0–24 months (services not covered).
Do not seek coverage for maintenance therapy or treatment when condition is not improving or resolving.
Confirm and obtain prior authorization when required by the member's plan or contract before performing visits beyond plan-specified limits.

Maintenance therapy is considered not medically necessary and is excluded when treatment is supportive rather than corrective.

ExamplesCare aimed to maintain or prevent deterioration of a chronic condition, prolong or enhance quality of life, or promote general health rather than achieve further clinical improvement.

Spinal problem categories

AcuteNew injury identified by x-ray or physical exam where improvement or arrest of progression is expected within a reasonable and generally predictable period (may require several weeks up to ~3 months); frequency of services should decrease as condition improves.

ChronicCondition not expected to be significantly resolved with further treatment but where continued therapy may yield some functional improvement.

ExacerbationTemporary marked deterioration due to an acute flare; must be documented including date, onset nature, and supporting factors for medical necessity.

RecurrenceReturn of symptoms of a previously treated condition after ≥30 days of quiescence; may require re‑institution of therapy.

Manual therapy / Spinal manipulative therapy

DefinitionManual therapy and spinal manipulative therapy: physical interventions (manual techniques and spinal manipulation) evaluated in multiple systematic reviews and clinical guidelines for musculoskeletal and some non‑musculoskeletal conditions.

Evidence baseEvaluated in numerous systematic reviews and clinical practice guidelines (see cited systematic reviews and guidelines in policy references).

ScopeApplied for management of musculoskeletal conditions such as low back pain and other indications discussed in referenced literature; benefits and harms have been systematically reviewed.

Caution for pediatricsAdverse events associated with pediatric spinal manipulation are noted in cited systematic reviews and should inform pediatric use and exclusions.