CurrentNeighborhood Health Plan of Rhode IslandPolicy #073

In Lieu Of Services for Chronic Pain (Chiropractic, Acupuncture, Massage)

Defines Neighborhood Health Plan of Rhode Island coverage and authorization requirements for chiropractic, acupuncture, and massage therapy when provided as in-lieu-of alternatives to medications or invasive procedures for chronic pain; applies to specified NHP lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu Of Services for Chronic Pain (Chiropractic, Acupuncture, Massage)

Policy CodePolicy #073

Change TypeAnnual review — no material changes

Effective DateDec 10, 2019

Next Review DateDec 11, 2024

Key ActionObtain prior authorization using the Neighborhood In Lieu Of Prior Authorization Request Form and attest that the service is being used as an in‑lieu‑of therapy for chronic pain.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12Chiropractic visits/yr

12Acupuncture visits/yr

6Massage visits/yr

Specified plansCovered plans

HBE, EFPExcluded plans

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In-Lieu-Of Services Coverage Criteria

In-Lieu-Of Services — Coverage Criteria

Covered when ALL of the following are met

In-lieu-of coverage criteria: Service is chiropractic, acupuncture, or massage therapy and is being requested as an in-lieu-of alternative to medications or invasive procedures for chronic pain; authorization is obtained using the Neighborhood In Lieu Of Prior Authorization Request Form; EOHHS authorization exists to utilize these services as in-lieu-of services.

Limits apply per rolling year: chiropractic 12, acupuncture 12, massage 6.

Coverage for in‑lieu‑of services described in this policy does not apply to members enrolled through the Health Benefit Exchange (HBE) or the Extended Family Plan (EFP). Requests for chiropractic, acupuncture, or massage as in‑lieu‑of therapies for chronic pain submitted for members in these lines of business will be excluded from coverage.

Coding and Frequency Limits

Visit limits per rolling year

Chiropractic12 visits per rolling year

Acupuncture12 visits per rolling year

Massage therapy6 visits per rolling year

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Neighborhood requires prior authorization for all approved in‑lieu‑of services (chiropractic, acupuncture, massage therapy). Use the Neighborhood In Lieu Of Prior Authorization Request Form when submitting requests.

Chiropractic services: AUTHORIZATION REQUIRED. LIMIT OF 12 per rolling year.
Acupuncture services: AUTHORIZATION REQUIRED. LIMIT OF 12 per rolling year.
Massage therapy: AUTHORIZATION REQUIRED. LIMIT OF 6 per rolling year.

Denial Risk

Denial Risk if Authorization Not Submitted

Failure to submit the required prior authorization form and supporting documentation may result in denial of the request. Ensure clinical rationale and documentation demonstrating that the in‑lieu‑of service is an appropriate substitute for medications or invasive procedures are provided.

Background

Neighborhood permits certain non‑pharmacologic therapies — specifically chiropractic, acupuncture, and massage — to be provided as in‑lieu‑of services when they are determined to be medically appropriate alternatives to medications or invasive procedures for chronic pain. These services are intended to improve member health and quality of life as substitutes for other covered state plan services and require authorization using the Neighborhood In Lieu Of Prior Authorization Request Form.

Definitions

In Lieu of Services — alternative services

Chiropractic servicesAuthorized as in-lieu-of services for chronic pain (in lieu of medications or invasive procedures); authorization required; limit applies per rolling year.

Acupuncture servicesAuthorized as in-lieu-of services for chronic pain (in lieu of medications or invasive procedures); authorization required; limit applies per rolling year.

Massage therapyAuthorized as in-lieu-of services for chronic pain (in lieu of medications or invasive procedures); authorization required; limit applies per rolling year.

Attestation and Conservative Treatment

Service Frequency Limits

Chiropractic services

Limit12 visits per rolling year

RequirementAuthorization required using the Neighborhood In Lieu Of Prior Authorization Request Form

UseProvided as an alternative to medications or invasive procedures for chronic pain when approved by EOHHS

Acupuncture services

Limit12 visits per rolling year

RequirementAuthorization required using the Neighborhood In Lieu Of Prior Authorization Request Form

Use

Imaging Requirements

Note

Imaging requirements

No specific imaging requirements are stated in the policy for these in-lieu-of services.

The policy lists covered lines of business but does not specify imaging or radiography prerequisites for chiropractic, acupuncture, or massage.

Not Covered

Not covered: the Health Benefit Exchange (HBE) and the Extended Family Plan (EFP) are explicitly excluded from coverage under this policy for in‑lieu‑of services.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu Of Services for Chronic Pain (Chiropractic, Acupuncture, Massage)

Policy CodePolicy #073

Change TypeAnnual review — no material changes

Effective DateDec 10, 2019

Next Review DateDec 11, 2024

Key ActionObtain prior authorization using the Neighborhood In Lieu Of Prior Authorization Request Form and attest that the service is being used as an in‑lieu‑of therapy for chronic pain.

SourceLink

On This Page

Requests without the Neighborhood In Lieu Of Prior Authorization Request Form may be denied.

Provide clinical documentation showing effectiveness for the member and improvement in health/quality of life.

Documentation Required

Required Prior Authorization Form and Documentation

Required documentation must include the completed Neighborhood In Lieu Of Prior Authorization Request Form and supporting clinical records. Include history of condition, prior treatments (medications, procedures), and justification for why the in‑lieu‑of service is an appropriate substitute.

Attach relevant clinical notes, prior treatment attempts, and treatment plan.
Specify the in‑lieu‑of service requested and the clinical rationale for substitution.

Note

Position Relative to Other Therapies

Position relative to other therapies: these in‑lieu‑of services are intended as alternatives to medications and invasive procedures for chronic pain when clinically appropriate. They may be used as substitutes for state plan services per EOHHS approval and Neighborhood determination of medical appropriateness.

Services are intended as alternatives to medications or invasive procedures, not automatic first‑line replacements.
Coverage is granted when Neighborhood determines the service is effective for the member and improves health/quality of life.

Provided as an alternative to medications or invasive procedures for chronic pain when approved by EOHHS

Massage therapy

Limit6 visits per rolling year

RequirementAuthorization required using the Neighborhood In Lieu Of Prior Authorization Request Form

UseProvided as an alternative to medications or invasive procedures for chronic pain when approved by EOHHS