CurrentMass General Brigham Health PlanPolicy 013

Chiropractic Services

Defines medical necessity, coverage, limitations, and coding guidance for chiropractic services for Mass General Brigham Health Plan members, with variations for Commercial/Qualified Health Plans, MassHealth ACO members, and Medicare Advantage members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyChiropractic Services

Policy CodePolicy 013

Change TypeAnnual and off-cycle updates (June 2025Jan 2025)

Effective DateJune 2025

Next Review Date

Key ActionObtain prior authorization for visits 21 and beyond for Commercial and Qualified Health Plans where a chiropractor benefit applies.

SourceLink

POLICY UPDATE CHANGES

Added LCDs to Medicare variation and updated references.

Prior authorization table updated and MassHealth variation language added.

Added exclusion for Maintenance Therapy.

20MassHealth limit (visits/yr)

1-20No PA (visits)

21+PA required

0-24moNot covered age

Coverage Criteria and Limitations

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Covered services (general)

Covered when ALL of the following are met and supported by InterQual criteria:

General coverage: Chiropractic adjustments/manipulations and supportive procedures are covered for medically necessary examination, evaluation, diagnosis, and treatment of neuromuscular and musculoskeletal conditions

See InterQual for specific clinical indicators and duration expectations

Chiropractic services are not covered for Commercial and Qualified Health Plan members aged 0 to 24 months. This exclusion is stated in the policy exclusions and has been carried through prior updates to the policy (see historical updates).

The policy also excludes maintenance therapy — defined as treatment that is supportive rather than corrective when no further clinical improvement is expected — as a basis for coverage. This exclusion was added in the August 2024 annual update and is reflected in the effective language of the policy.

Care described as maintenance therapy — ongoing treatment intended to prevent deterioration or simply maintain a chronic condition when further clinical improvement is not expected — is considered not medically necessary and is excluded from coverage.

Providers should document expected clinical improvement and objective findings that support continued therapeutic intervention; treatment that does not demonstrate improvement or resolution of the treated condition meets the policy definition of not medically necessary.

Billing, Codes, and Visit Limits

Commercial and MassHealth applicable modality and therapy codesCPT

97010
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
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 20

1/2

CMT and E/M codesCPT

98941	Chiropractic manipulative treatment (CMT), spinal, three to four regions.
98942	CMT, spinal, five regions.
98943	CMT, extraspinal, 1 or more regions.
99202	Office/outpatient visit for new patient, low to moderate severity.
99203	Office/outpatient visit for new patient, moderate severity.
99204	Office/outpatient visit for new patient, moderate to high severity.
99205	Office/outpatient visit for new patient, moderate to high severity.
99211	Office/outpatient visit for established patient; minimal problem.
99212	Office/outpatient visit for established patient; self-limited or minor.
99213	Office/outpatient visit for established patient, low to moderate severity.

1–10 of 12

1/2

MassHealth visit limit — 20 visits per benefit year

MassHealth visit limitMassHealth plans limit coverage for chiropractic services to a total of 20 office visits per benefit year.

Authorization threshold (Commercial/Qualified)No prior authorization for Visits 1-20; authorization required for Visits 21 and beyond where chiropractor benefit applies (see plan materials).

Authorization threshold (MassHealth)No prior authorization for Visits 1-20; authorization required for Visits 21 and beyond; visits 21 and beyond are not covered for MassHealth.

Provider Requirements, Authorization, and Denials

Prior Authorization

Prior Authorization Requirements

Visits 1–20 do not require prior authorization for Commercial and Qualified Health Plans that include a chiropractor benefit and for MassHealth and Medicare Advantage per plan variation; Visits 21 and beyond require prior authorization for Commercial and Qualified Health Plans (where a chiropractor benefit applies). Refer to plan materials for Commercial/Qualified Health Plan prior authorization processes.

Prior authorization required for Visits 21+ for Commercial and Qualified Health Plans (when chiropractor benefit applies).
MassHealth: coverage limited to 20 office visits per benefit year; see MassHealth variation.
Medicare Advantage: follows Medicare variation — refer to plan materials and LCDs.

Documentation Required

Documentation and Medical Necessity Determination

Medical necessity is determined using InterQual criteria as customized by Mass General Brigham Health Plan. Providers must document clinical findings, trial of conservative therapies (when applicable), functional limitations, and treatment progress to demonstrate ongoing medical necessity. Use the InterQual Criteria Lookup on the plan website for the specific criteria and code lists.

Medical necessity = InterQual criteria customized by Mass General Brigham Health Plan.
Provider documentation should include: history, exam findings, prior conservative care, objective functional status, number of visits, and response to treatment.
Access InterQual via MassGeneralBrighamHealthPlan.org > Resources > InterQual Criteria Lookup.

Step Therapy

There is no specific step therapy protocol for chiropractic services. Coverage and progression of care are determined by meeting InterQual medical necessity criteria and plan benefit limits; providers should follow InterQual guidance for initial and continuation therapy.

No formal step therapy rules — authorization/coverage determined by InterQual criteria and plan benefit limits.
If InterQual requires prior conservative treatments as part of medical necessity, document those interventions in the record.

Denial Risk

Denial Triggers

Services may be denied when visit limits or age exclusions are exceeded, when InterQual medical necessity criteria are not met, or when required documentation is missing. MassHealth-specific denials occur if more than 20 visits/benefit year are billed or for services to prohibited age groups per plan exclusions.

Denial triggers: exceeding MassHealth 20-visit limit per benefit year.
Denial triggers: services not meeting customized InterQual medical necessity criteria.
Denial triggers: providing chiropractic services to excluded age groups (see exclusions) or missing required provider documentation.
Denial triggers: failure to obtain required prior authorization for visits 21+ where applicable.

Definitions

Chiropractic Services — definition

DefinitionServices rendered by a licensed chiropractor that consist of manual technique where the hands are used to manipulate, mobilize, adjust, stimulate, or otherwise influence the synovial joints and paraspinal tissues in the spinal column.

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

ProviderMust be rendered by a licensed chiropractor and may include manipulative techniques and supportive procedures as adjuncts.

Chiropractic Manipulative Treatment — definition

DefinitionCorrection of misalignments, subluxations, or segmental joint dysfunction of the bony articulations of the vertebral column, the pelvis, and adjacent areas.

ScopeApplies to manipulative treatment of spinal regions and adjacent areas as performed by chiropractors.

Coding noteSee CMT codes (e.g., 98941–98943) in the coding section for billing of chiropractic manipulative treatment.

Maintenance Therapy — definition and exclusion rationale

DefinitionA treatment plan intended to prevent deterioration, promote health, or maintain a chronic condition when further clinical improvement cannot reasonably be expected; care that is supportive rather than corrective.

Coverage stanceMaintenance therapy is excluded — treatment that is supportive rather than corrective and when no further clinical improvement is expected is not covered or is considered not medically necessary.

Clinical implicationIf ongoing care does not produce further improvement and is aimed only at maintaining status, it meets the definition of maintenance therapy and is excluded from coverage.

Supportive Procedures and Therapies — adjunctive modalities and therapies

DefinitionAdjunctive modalities and therapies administered, dispensed, or prescribed in addition to primary chiropractic procedures (e.g., braces, casting, supports, traction, thermal modalities, ultrasound, electrical modalities, hydrotherapy, myotherapy, dietary/nutritional advice, and rehabilitative exercise therapy).

PurposeTo aid the chiropractor in assisting a patient to achieve a timely and favorable clinical outcome; not required to be applied in practice of chiropractic.

RoleConsidered supportive procedures used alongside manipulative techniques to improve clinical outcomes, not as replacement for primary chiropractic treatment.

Background

Chiropractic services encompass manual techniques performed by licensed chiropractors, including adjustments and manipulations intended to restore or improve joint mobility and neuromuscular function. These services may also include supportive procedures and adjunctive therapies used to aid clinical outcomes.

The clinical goal of chiropractic care in this policy is corrective treatment that produces measurable improvement in a neuromuscular or musculoskeletal condition. Interventions intended only to maintain function without expectation of further improvement are classified as maintenance therapy and are excluded from coverage.

Policy Revision History and Updates

2025-06annual_updateLatest

Added LCDs to Medicare variation and updated references (annual update effective June 2025).

2025-01off-cycle_update

Prior authorization table updated and MassHealth variation language added (off-cycle update January 2025).

2024-08annual_update

Added exclusion for Maintenance Therapy (annual update August 2024).

2018-10off-cycle_update

Revised exclusion language to reflect chiropractic services not covered for members aged 0–24 months (off-cycle update October 2018).

2016-11effective_date

Policy effective (InterQual criteria integration noted in subsequent 2017 update).