CurrentmhnPolicy N/A

Chiropractic and Acupuncture Coverage

Defines covered chiropractic and acupuncture services, visit limits, copayments, covered conditions, and exclusions for Health Net members accessing care via the ASH Plans network. Affects members who select participating ASH Plans providers and providers administering these services.

Policy Summary

Payermhn

PolicyChiropractic and Acupuncture Coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain acupuncture or chiropractic care from participating ASH Plans network providers; consult the member's EOC or Health Net for plan-specific authorization rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20maximum visits per calendar year

$10office visit copayment

2service sections

multiplecovered condition examples

Coverage Criteria for Chiropractic and Acupuncture

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Visit and payment limits: Office visits have a $10 copayment per visit, up to 20 visits per calendar year; includes initial exam, follow-up visits, and reexaminations.up to 20 visits/year

copayment applies per visit

Clinical indication: Services are for musculoskeletal and related disorders such as headache; back or neck pain; shoulder, hip, and knee joint pain; osteoarthritis and other arthritic pain; pain involving other joints and associated soft tissues; degenerative joint diseases/arthropathies; neurological conditions; inflammatory disorders; sprain/strain injuries to the spine and extremities; intervertebral disc injuries/disorders; muscular spasms and myalgias; and nausea indications including postoperative nausea and vomiting, pregnancy-associated nausea, and chemotherapy-associated nausea.clinical diagnosis as listed

nausea indications may require co-management with the member's provider

Provider/network requirement: Care must be obtained from participating ASH Plans network chiropractors or acupuncturists; members may consult their PCP but a referral is not required.provider in ASH Plans network

membership and network details available in the member's Evidence of Coverage (EOC)

The policy specifically excludes devices and personal/comfort items (for example, air conditioners, air purifiers, therapeutic mattresses, durable medical equipment, appliances, vitamins, minerals, and nutritional supplements) when billed under the chiropractic or acupuncture benefits. It also excludes diagnostic scanning such as MRI, CT, and thermography. These items and services are not covered under the chiropractic/acupuncture programs and may instead be reviewed under the member’s medical benefits when appropriate.

Exams and treatments that are unrelated to musculoskeletal or neuromusculoskeletal disorders (including interventions not intended for pain, nausea, or other covered indications listed in the policy) are not covered under these programs. Services outside the defined scope of acupuncture or chiropractic care may be denied when billed to these benefits and should be submitted, if appropriate, under the member’s medical benefits.

Provider Actions, Authorization, and Denial Risks

Prior Authorization

Prior authorization not specified

Prior authorization is not specified in this document. Providers and members should consult the plan's Evidence of Coverage (EOC) or contact Health Net to determine if prior authorization is required for specific services.

Contact Health Net at 1-800-275-4737 (TTY: 711).
EOC guidance determines prior authorization and coverage details.

Step Therapy

Step therapy

No step therapy requirements are specified in this document.

Note

Member and provider resources

For member and provider resources, consult the plan Evidence of Coverage (EOC) or contact Health Net for hours and support. Phone: 1-800-275-4737 (TTY: 711).

Office hours Oct 1–Mar 31: seven days/week, 8 a.m.–8 p.m.
Office hours Apr 1–Sep 30: Mon–Fri, 8 a.m.–8 p.m.
A messaging system is used after hours, weekends, and federal holidays.

Denial Risk

Chiropractic exclusions that may trigger denial

Services and supplies excluded under the chiropractic care program may trigger denials when billed under that benefit. Examples of commonly excluded items include diagnostic scanning, MRI, CT scans, thermography, and certain devices.

Excluded imaging: MRI, CT, diagnostic scanning, thermography.
Excluded items: devices, personal and comfort items.

Denial Risk

Acupuncture exclusions that may trigger denial

Services and supplies excluded under the acupuncture care program may trigger denials when billed under that benefit. Examples include devices and diagnostic scans. Some excluded services may be covered under the medical benefits portion of the plan; consult the EOC.

Excluded: devices and personal/comfort items.
Excluded imaging: diagnostic scanning, MRI, CT scans, thermography.
If medical benefits may apply, refer to the plan Evidence of Coverage.

Covered Conditions — Examples

Covered conditions (examples) — chiropractic/acupuncture

Common musculoskeletal painBack or neck pain; shoulder, hip, and knee joint pain; pain involving other joints and associated soft tissues

Arthritic conditionsOsteoarthritis and other arthritic pain; degenerative joint diseases/arthropathies

Neurologic and soft-tissue disordersNeurological conditions; inflammatory disorders; sprain/strain injuries; intervertebral disc injuries/disorders; muscular spasms and myalgias

HeadacheHeadache(s) including related pain syndromes

Nausea indicationsPostoperative nausea and vomiting (PONV), nausea associated with pregnancy, and chemotherapy-related nausea (may require co-management with provider)

Background

Acupuncture and chiropractic services are available through participating ASH Plans network providers for treatment of musculoskeletal and related disorders. Coverage is focused on neuromusculoskeletal conditions and related indications (for example, headache, back or neck pain, joint and soft-tissue pain, osteoarthritis, sprain/strain injuries, degenerative joint disease, and certain nausea indications). Members should obtain care from ASH Plans network chiropractors or acupuncturists; services include the initial exam, follow-up visits, and reexaminations and are subject to a $10 copayment per visit with a combined limit of up to 20 visits per calendar year.