CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

In Lieu of Services for chronic pain (chiropractic, acupuncture, massage)

Defines Neighborhood Health Plan of RI coverage, coding, limits, and prior authorization expectations for selected alternative therapies provided in lieu of state plan services for eligible Medicaid and INTEGRITY members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu of Services for chronic pain (chiropractic, acupuncture, massage)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateJan 1, 2023

Key ActionUse the Neighborhood In Lieu Of Prior Authorization Request Form to attest that the service is being used 'in lieu of' the described State Plan Service and verify eligibility before rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12chiropractic visit limit

12acupuncture visit limit

6massage therapy visit limit

97810-97814acupuncture codes

98940-98942chiropractic codes

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Coverage Criteria

General coverage criteria

Services may be covered when ALL of the following are met:

ALL of the following

Service is being provided as an In Lieu of Service — an alternative service approved by RI EOHHS to be used as a substitute for a described State Plan Service.
The service is determined to be effective in the treatment of the member's pain and improves the member's quality of health.
The requesting provider attests, using the Neighborhood In Lieu Of Prior Authorization Request Form, that the service is being used 'in lieu of' the described State Plan Service and verifies member eligibility and coverage prior to rendering services.
All services are medically necessary; Neighborhood may apply National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), industry-accepted criteria such as InterQual, EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMPs) to determine medical necessity.
Covered services under this policy include chiropractic services, acupuncture services, and massage therapy when used in lieu of medications or invasive procedures for chronic pain.
Benefit limits apply (rolling year): chiropractic services — 12 visits; acupuncture services — 12 visits; massage therapy services — 6 visits.

Coding and Visit Limits

Acupuncture codesCPTCovered

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).

Massage/therapy codesCPTCovered

97124	Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).
97110	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
97112	Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
97140	Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.
97150	Therapeutic procedure(s), group (2 or more individuals).
97530	Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

Chiropractic codesCPTCovered

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.

Chiropractor with physiotherapy license - modality codesCPTCovered

97010	Application of a modality to 1 or more areas; hot or cold packs.
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.

Visit limits (rolling year) - inv-06: Visit limits

Chiropractic (visits per rolling year)12 visits per rolling year

Acupuncture (visits per rolling year)12 visits per rolling year

Massage therapy (visits per rolling year)6 visits per rolling year

Provider Actions and Prior Authorization

Prior Authorization

Attest using Neighborhood In Lieu Of Prior Authorization Request Form

Use the Neighborhood In Lieu Of Prior Authorization Request Form to attest that the requested service is being provided “in lieu of” the described State Plan Service; the requesting provider must attest and verify eligibility, coverage and authorization criteria prior to rendering services.

Provider must complete the Neighborhood In Lieu Of Prior Authorization Request Form and attest the service is used 'in lieu of' the State Plan service.
Provider is responsible for verifying member eligibility, coverage and authorization before providing services.

Documentation Required

Medical necessity determinations and accepted criteria

All services must be medically necessary for reimbursement; Neighborhood may apply NCDs, LCDs, InterQual, EOHHS recommendations, and Clinical Medical Policies (CMPs) to determine medical necessity.

Definitions

In Lieu of Services - inv-09: Definition

DefinitionAlternative services provided as substitutes for state plan services when approved by the Rhode Island Executive Office of Health and Human Services (EOHHS) and determined medically appropriate.

Approval authorityServices identified in this document have been approved by RI EOHHS to be utilized as 'In Lieu of' services.

Neighborhood policy positionNeighborhood may (but is not required to) provide these alternative services when medically appropriate.