CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Complementary and Alternative Medicine (CAM) services: chiropractic and acupuncture coverage

Policy governs coverage of chiropractic and acupuncture services (CAM) for Neighborhood Health Plan of Rhode Island commercial lines, defines benefit limits, excluded massage therapy, coding and claim submission rules.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyComplementary and Alternative Medicine (CAM) services: chiropractic and acupuncture coverage

Policy CodePolicy N/A

Change TypeDocument review (no material clinical changes)

Effective DateJul 1, 2018

Next Review Date

Key ActionProvider must verify member eligibility, coverage and authorization criteria prior to rendering services and document medical necessity per Neighborhood references (LCD, NCD, InterQual, EOHHS, CMP).

POLICY UPDATE CHANGES

07/16/20 noted as policy review date; policy effective 07/01/18.

2Covered Service Types

3Covered Acupuncture Diagnoses

12Chiropractic visit limit (per year)

12Acupuncture visit limit (per year)

1Excluded Service Types (massage)

Coverage Summary

Policy governs coverage of chiropractic and acupuncture services (CAM) for Neighborhood Health Plan of Rhode Island commercial lines, defining benefit limits, exclusions, coding and claim submission rules. Effective date: 2018-07-01; Last review: 2020-07-16. CAM is defined as: "Complementary and Alternative Medicine services defined as treatment from a chiropractor, acupuncturist, and/or massage therapist." The plan takes a mixed coverage stance: chiropractic and acupuncture are covered with visit limits, while massage therapy is excluded.

Coverage limits and summary

Chiropractic visit limit12 visits per year (rolling)

Acupuncture visit limit12 visits per year (rolling)

Covered Service Types2

Covered Acupuncture Diagnoses3

Excluded Service Types (massage)1

Medical-Necessity Criteria

Not Covered / Excluded Services

Excluded Services

All services must be medically necessary to qualify for reimbursement. Neighborhood uses the following to determine medical necessity and requires provider verification prior to rendering services.

ALL of the following

Accepted references
- Local Coverage Determination (LCD)
- National Coverage Determination (NCD)
- Industry accepted criteria such as InterQual
- EOHHS recommendations

Coding

Acupuncture CPTCPTCovered

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97811	Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)
97813	Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)

Chiropractic CPT/HCPCSCPTCovered

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

Provider Actions

Documentation Required

Verify medical necessity and authorizations

Provider must verify member eligibility, coverage and authorization criteria prior to rendering services and document medical necessity per Neighborhood references (LCD, NCD, InterQual, EOHHS, CMP).

Local Coverage Determination (LCD)
National Coverage Determination (NCD)
InterQual
EOHHS recommendations
Neighborhood Clinical Medical Policies (CMP)

Billing Rule

Claim submission timeliness

Providers must submit complete claims for payment within 90 days of the date services are provided.

Background

This policy defines CAM services as treatment from a chiropractor, an acupuncturist, and/or a massage therapist and states the plan's coverage stance: chiropractic and acupuncture are covered with limits, while massage therapy is excluded due to insufficient medical necessity criteria. Coverage and medical necessity determinations rely on Local Coverage Determinations (LCD), National Coverage Determinations (NCD), industry-accepted criteria such as InterQual, EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP). The policy also references coding and claim submission rules, including applicable CPT/HCPCS codes and timely claim submission requirements.

Definitions

CAM: Complementary and Alternative Medicine services defined as treatment from a chiropractor, an acupuncturist, and/or a massage therapist.

Revision History

2018-07-01effective_date

Policy effective date per document history.

2020-07-16review_dateLatest

07/16/20 noted as policy review date; no clinical policy statement changes indicated.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyComplementary and Alternative Medicine (CAM) services: chiropractic and acupuncture coverage

Policy CodePolicy N/A

Change TypeDocument review (no material clinical changes)

Effective DateJul 1, 2018

Next Review Date

On This Page

Neighborhood Clinical Medical Policies (CMP)

Provider verification: Provider must verify eligibility, coverage and authorization criteria prior to rendering services

title': 'General Medical Necessity

title": "General Medical Necessity"} } , {

citations": ["4","3"],

intro": "CAM services are covered when they meet plan limits and diagnosis restrictions.",

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title": "Covered Services and Limits"

citations": ["0","4"],

intro": "Services excluded from coverage:",

nodes": ["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"\",\"threshold\":\"\",\"note\":\"\",\"children\":[{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Massage therapy is excluded from coverage due to insufficient medical necessity criteria\",\"threshold\":\"\",\"note\":\"\",\"children\":[]},{\"operator\":\"all\",\"n\":0,\"label\":\"X-ray documentation only\",\"text\":\"No coverage or payment for X-rays or other diagnostic/therapeutic services ordered or furnished by chiropractors to demonstrate subluxation of the spine; X-rays may be used for documentation only\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}]}"],

title": "Excluded Services"

Massage therapy is specifically excluded from coverage because there is insufficient medical necessity criteria to support reimbursement. When chiropractors order, take, or interpret X-rays (or other diagnostic procedures) to demonstrate spinal subluxation, those images may be used for documentation only and there is no coverage or payment for those diagnostic or therapeutic services.

Documentation Required

X-ray documentation only

If a chiropractor orders, takes, or interprets an X-ray or other diagnostic procedure to demonstrate subluxation of the spine, the X-ray may be used for documentation only; there is no coverage or payment for those diagnostic or therapeutic services ordered or furnished by the chiropractor.