CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Complementary and Alternative Medicine (CAM) payment and coverage

Defines reimbursement, coverage limits, coding, and claim submission rules for complementary and alternative medicine services (chiropractic and acupuncture) for Neighborhood Health Plan of Rhode Island Medicaid members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyComplementary and Alternative Medicine (CAM) payment and coverage

Policy CodePolicy N/A

Change TypeAnnual reviewcoding table added (non-material)

Effective DateN/A

Next Review DateSep 29, 2021

Key ActionVerify member eligibility, coverage, and authorization criteria prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

Updated Policy to Include Physiotherapy Coding Table.

Annual policy review noted with no content changes on 09/29/21.

12 visitsChiropractic services limit per rolling year

12 visitsAcupuncture services limit per rolling year

3 diagnosesDiagnoses for which acupuncture is covered

90 daysClaim submission timeframe

97810-97814, 98940-98942

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Coverage and Exclusions for CAM Services

CAM coverage and exclusions

Covered services and limitations

Services are subject to the following coverage rules and limits:

ALL of the following

Chiropractic services
Coverage status: Covered with criteria
Limit: Limited to 12 visits per rolling year
Diagnostic imaging: If a chiropractor orders, takes, or interprets an x-ray or other diagnostic procedure to demonstrate a subluxation of the spine, the x-ray may be used for documentation only; there is no separate coverage or payment for these diagnostic or therapeutic services when performed by the chiropractor.

ALL of the following

Acupuncture services
Coverage status: Covered with criteria
Limit: Limited to 12 visits per rolling year
Covered indications: Acupuncture is covered only for chronic low back pain, fibromyalgia, and chronic migraine.

ALL of the following

Massage therapy services
Coverage status: Not covered (excluded).

Approved Codes, Visit Limits, and Coding Rules

Approved codes for acupuncturists and chiropractorsCPTCovered

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) (List separately in addition to code for primary procedure).
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) (List separately in addition to code for primary procedure).
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.
97010	Application of a modality to 1 or more areas; hot or cold packs

Additional approved therapy and modality codesCPTCovered

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	Application of a modality to 1 or more areas; vasopneumatic devices.
97018	Application of a modality to 1 or more areas; paraffin bath.
97022	Application of a modality to 1 or more areas; whirlpool.
97024	Application of a modality to 1 or more areas; diathermy (eg, microwave).
97026	Application of a modality to 1 or more areas; infrared.
97028	Application of a modality to 1 or more areas; ultraviolet.
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.
97033	Application of a modality to 1 or more areas; iontophoresis, each 15 minutes.

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Visit limits per rolling year — Chiropractic and Acupuncture

Chiropractic visit limit12 visits per rolling year

Acupuncture visit limit12 visits per rolling year (coverage limited to chronic low back pain, fibromyalgia, and chronic migraine)

Massage therapyExcluded from coverage

Chiropractor-performed diagnostic x‑raysX‑rays ordered/taken/interpreted by a chiropractor may be used for documentation but are not separately payable

Prior Authorization, Verification, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

All services must be medically necessary to qualify for reimbursement. Neighborhood may use National Coverage Determinations (NCD), Local Coverage Determinations (LCD), industry-accepted criteria (e.g., InterQual), Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP) to determine medical necessity. It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services. For plan-specific prior authorization requirements and procedures, refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies. Contact Provider Services at 1-800-963-1001 for questions related to this policy.

Verify eligibility, coverage, and authorization prior to services
Medically necessary services only
Reference Neighborhood Prior Authorization Reference page
Reference Neighborhood Clinical Medical Policies
Provider Services: 1-800-963-1001

Key Definitions

Complementary and Alternative Medicine (CAM) — definition

CAM definitionComplementary and Alternative Medicine (CAM) is defined as non-conventional services that are used together with or in place of conventional medical care.

ScopeIncludes services utilized together with or instead of conventional medical care

Policy focusThis policy sets reimbursement rules for CAM services for Neighborhood Health Plan of Rhode Island Medicaid members