Chiropractic Services
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Defines Moda Health coverage, medical necessity criteria, exclusions, and prior authorization information for chiropractic services for members with applicable benefits.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial coverage criteria
Covered when ALL of the following are met:
Applies to plans with a chiropractic rider and plans that do not limit chiropractic services.
Continuation therapy
Continuation of care covered when:
Maintenance programs to prevent regression are NOT covered.
Maintenance programs intended to prevent regression are not covered. Moda Health explicitly states that maintenance care designed to prevent regression of a condition or function is excluded from coverage and is not a covered benefit.
A number of procedures are considered investigational and not covered. Examples listed in the policy include spinal manipulation under anesthesia, thermography, paraspinal or surface EMG, techniques such as the Graston technique, spinoscopy, thermomechanical massage, and other named modalities. The policy also explicitly lists codes and services that are not covered, including 22505 (manipulation of the spine requiring anesthesia), S3900 (surface EMG), and S8990 (physical or manipulative therapy performed for maintenance rather than restoration).
Manipulation of infants (under 1 year) is considered investigational and not covered for all indications, and chiropractic manipulation of adolescents under 13 years for non‑musculoskeletal conditions is also considered investigational and not covered.
Services are considered not medically necessary / not covered when provided as maintenance care whose intent is to prevent regression rather than to restore function. The policy states that maintenance programs to prevent regression are explicitly excluded.
Specific procedures and indications listed by Moda Health are considered investigational and therefore not medically necessary. These include, but are not limited to, spinal manipulation under anesthesia, thermography, paraspinal EMG / surface scanning EMG, manipulation for non‑musculoskeletal conditions, chiropractic management of scoliosis, dry hydrotherapy, Graston technique, spinoscopy, and thermomechanical massage.
Age‑specific not medically necessary statements: manipulation of infants under 1 year is investigational for all indications and chiropractic manipulation of adolescents under 13 years for non‑musculoskeletal conditions is investigational and not covered.
Providers should note the explicit not‑covered billing codes identified in the policy (for example, 22505, S3900, and S8990); claims for these services will be denied as not covered or not medically necessary when billed for excluded or investigational uses.
CPT / HCPCS Coding
| 98940 | Chiropractic manipulative treatment (CMT); spinal, one to two regions. |
| 98941 | Chiropractic manipulative treatment (CMT); spinal, three to four regions. |
| 98942 | Chiropractic manipulative treatment (CMT); spinal, five regions. |
| 98943 | Chiropractic manipulative treatment (CMT); extraspinal, one or more regions. |
Prior Authorization and Documentation Requirements
Prior authorization documentation required
Prior authorization requests must include supporting chart notes and chiropractic evaluation/progress notes that document medical necessity and a plan for continued therapy for the requested CMT codes (98940–98943).
- Chart notes from PCP or specialist documenting the diagnosis
- Original evaluation and progress notes from the chiropractic provider including a plan for continued therapy
- Documentation must show medical necessity and a treatment plan for continued services
Reserved for any additional provider-action notes identified in the inventory; no specific step-therapy requirements or extra actions are listed in this policy.
Required documentation for prior authorization
Include chart notes from the PCP or specialist that document the diagnosis, plus the chiropractic provider’s original evaluation and progress notes that include a plan for continued therapy.
- PCP or specialist chart notes documenting the diagnosis
- Chiropractic original evaluation
- Chiropractic progress notes documenting response to care and plan for continued therapy
Denial triggers — not-covered codes and maintenance therapy
Services billed with explicitly not-covered codes or billed as maintenance therapy are subject to denial.
- Do not submit or expect coverage for codes listed as not covered: 22505 (manipulation of spine requiring anesthesia), S3900 (surface electromyography), S8990 (physical or manipulative therapy performed for maintenance rather than restoration).
- Maintenance programs intended to prevent regression are NOT covered and will be denied.
Background and Rationale
Chiropractic care is a noninvasive, hands‑on, regulated health profession focused on the relationship between the spinal column, neuromusculoskeletal structures, and the nervous system to restore and maintain health. The practice treats the spine, muscles, joints, and related tissues within the scope of a licensed chiropractic physician.
Moda Health covers chiropractic services when the member has a musculoskeletal disorder, the treatment is provided by a legally qualified chiropractic physician practicing within the scope of their license, and the medical necessity for treatment is documented. Continuation of care is considered medically necessary until maximum therapeutic benefit is achieved; lack of clinical response between treatments indicating a plateau supports transition to a home exercise and stretching program.
Definitions
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