CurrentOrthoNetPolicy 496

Medicare Chiropractic Services

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Medicare Advantage coverage and prior authorization for chiropractic services, limited to manual manipulation of the spine to correct a documented spinal subluxation.

Policy Summary

PayerOrthoNet

PolicyMedicare Chiropractic Services

Policy CodePolicy 496

Change TypeRevised

Effective DateFeb 11, 2026

Last ReviewFeb 11, 2026

Next Review DateNot specified

Key ActionFor care beyond the initial course, document interval history and examination, change in condition, treatment effectiveness, treatment provided, and proposed frequency and duration.

SourceLink

POLICY UPDATE CHANGES

Documentation requirements supporting the medical necessity and reasonableness of chiropractic care beyond the initial course of treatment were revised.

1 service typeCovered chiropractic service

2 of 4Physical-examination findings required

5 regionsSpinal regions recognized

3 codesReference procedure codes

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CurrentOrthoNetPolicy 496

Medicare Chiropractic Services

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Sign up for orthonet Policy 496 alerts

Get alerted when Policy 496 changes without checking for updates manually.

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Medicare Advantage coverage and prior authorization for chiropractic services, limited to manual manipulation of the spine to correct a documented spinal subluxation.

Policy Summary

PayerOrthoNet

PolicyMedicare Chiropractic Services

Policy CodePolicy 496

Change TypeRevised

Effective DateFeb 11, 2026

Last ReviewFeb 11, 2026

Next Review DateNot specified

Key ActionFor care beyond the initial course, document interval history and examination, change in condition, treatment effectiveness, treatment provided, and proposed frequency and duration.

SourceLink

POLICY UPDATE CHANGES

Documentation requirements supporting the medical necessity and reasonableness of chiropractic care beyond the initial course of treatment were revised.

1 service typeCovered chiropractic service

2 of 4Physical-examination findings required

5 regionsSpinal regions recognized

3 codesReference procedure codes

Not coveredMaintenance therapy

Covered and Non-Covered Chiropractic Services

General coverage requirements

Covered when all of the following are met:

General medical necessity requirements

The patient has a significant neuromusculoskeletal condition requiring treatment, and the manipulation has a direct therapeutic relationship to the condition with a reasonable expectation of recovery or improvement of function.
The primary diagnosis is spinal subluxation demonstrated by x-ray or physical examination.
The precise level of subluxation is specified.
Manual manipulation of one or more spinal regions is planned.

Physical examination subluxation criteria

For physical-examination demonstration of subluxation, all of the following logic applies:

Physical examination subluxation evidence

At least 2 of 4 findings
- Pain or tenderness evaluated by location, quality, and intensity.
- Asymmetry or misalignment identified at a sectional or segmental level.
  Must be one of the required findings.
- Range-of-motion abnormality.
  Must be one of the required findings.
- Tissue-tone changes in contiguous or associated soft tissues, including skin, fascia, muscle, or ligament.

Care beyond the initial course

Care beyond the initial course is considered when all of the following documentation elements support further treatment:

Continued-care documentation

Review of the chief complaint is documented.
Changes since the last visit are documented, including relevant system review.
The area of the spine involved in the diagnosis is examined.
Change in the patient's condition since the last visit is assessed.
Treatment effectiveness is evaluated.

Not medically necessary services

The following services or circumstances are not medically necessary:

Noncovered clinical circumstances

Chiropractic maintenance therapy when further clinical improvement cannot reasonably be expected and care has become supportive rather than corrective.
Chiropractic manipulation for a non-neuromusculoskeletal condition.

Services furnished or ordered by chiropractors are not covered unless they consist of manual manipulation of the spine to correct a documented subluxation. This limitation applies to services outside the Medicare chiropractic spinal-manipulation benefit.

Maintenance therapy is not medically reasonable or necessary when further clinical improvement cannot reasonably be expected from continuous ongoing care. Treatment that has become supportive rather than corrective is considered maintenance therapy.

Chiropractic manipulation for non-neuromusculoskeletal conditions is not medically necessary under this policy. Covered treatment must address a significant neuromusculoskeletal condition with a direct therapeutic relationship to the condition.

Procedure Codes and Coding Requirements

CPT Procedure CodesCPT

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

Physical-examination subluxation findings

Required findingsAt least 2 of 4 physical-examination findings must be documented.

Required qualifying findingAt least 1 finding must be asymmetry/misalignment or range-of-motion abnormality.

Four findingsPain/tenderness; asymmetry or misalignment; range-of-motion abnormality; or tissue-tone changes in contiguous or associated soft tissues.

Spinal manipulation

Treatment typeManual manipulation as chiropractic manipulative treatment (CMT).

Spinal regionsManipulation of 1 or more spinal regions is planned.

Authorization and Documentation Requirements

Prior Authorization

Initial Course Authorization

Submit an initial course request only when the patient has a significant neuromusculoskeletal condition requiring treatment, the condition has a direct therapeutic relationship to the requested manipulation, and recovery or functional improvement is reasonably expected. Document spinal subluxation and plan manual manipulation of one or more spinal regions; the Medicare chiropractic benefit covers only covered manipulation to correct documented subluxation.

Primary diagnosis: spinal subluxation demonstrated by x-ray or physical examination.
Specify the precise spinal level and the region(s) planned for manual manipulation.
For CMT coding reference, CPT 98940 covers 1–2 regions, 98941 covers 3–4 regions, and 98942 covers 5 regions.

Prior Authorization

Authorization for Continued Care

Requests beyond the initial course must establish the medical necessity and reasonableness of continued chiropractic treatment. Explain the patient's ongoing need, expected benefit, and why further corrective care remains appropriate rather than supportive maintenance care.

Policy Scope and Coverage Context

Medicare chiropractic coverage is narrowly limited to manual manipulation of the spine to correct a documented subluxation. Coverage requires a significant neuromusculoskeletal condition requiring treatment, a direct therapeutic relationship between the manipulation and the condition, and a reasonable expectation of recovery or functional improvement. The subluxation must be demonstrated by x-ray or physical examination, its precise level must be specified, and manipulation of one or more spinal regions must be planned.

Key Policy Definitions

Subluxation

DefinitionA motion segment in which alignment, movement integrity, and/or physiological function of the spine are altered.

Joint-surface contactContact between joint surfaces remains intact.

DemonstrationA subluxation may be demonstrated on x-ray or physical examination.

Manual manipulation

DefinitionChiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function.

TechniquesThe treatment is accomplished using a variety of techniques.

Expected result

Policy Summary

PayerOrthoNet

PolicyMedicare Chiropractic Services

Policy CodePolicy 496

Change TypeRevised

Effective DateFeb 11, 2026

Last ReviewFeb 11, 2026

Next Review DateNot specified

Key ActionFor care beyond the initial course, document interval history and examination, change in condition, treatment effectiveness, treatment provided, and proposed frequency and duration.

SourceLink

On This Page

Treatment provided on the date of service is documented.

Treatment frequency, duration, and anticipated session length are documented.

Coverage contextManual manipulation must address a documented spinal subluxation.

Include updated history, examination findings, treatment effectiveness, treatment provided, and proposed frequency, duration, and anticipated treatment-session length.
All ongoing care is reviewed by an Optum clinical specialist provider and remains subject to applicable benefit restrictions and mandates.

Documentation Required

Document Subluxation

Demonstrate the spinal subluxation by x-ray or physical examination and identify the precise affected spinal level. If using physical examination evidence, document at least two of the four required findings, including asymmetry/misalignment or range-of-motion abnormality.

Pain or tenderness: location, quality, and intensity.
Asymmetry or misalignment at a sectional or segmental level.
Range-of-motion abnormality.
Tissue or tone changes involving contiguous or associated skin, fascia, muscle, or ligament.

Documentation Required

History and Presenting Illness

Record the relevant personal and family health history and provide a complete description of the present illness. Connect the presenting symptoms directly to the level of subluxation and describe the clinical context supporting treatment.

Symptoms prompting treatment, including quality and character.
Mechanism of trauma; onset, duration, intensity, frequency, location, and radiation.
Aggravating or relieving factors; prior interventions, treatments, medications, and secondary complaints.

Documentation Required

Examination and Diagnosis

Document a musculoskeletal and nervous-system physical examination and make subluxation the primary diagnosis. Identify the level of subluxation explicitly or use a diagnostic term describing the involved spinal joint or the direction of the affected bone.

Include examination findings supporting the diagnosed subluxation.
The primary diagnosis must be spinal subluxation, with the affected level specified.

Documentation Required

Initial Treatment Plan

Submit a treatment plan that defines the recommended level of care and provides a measurable basis for evaluating whether treatment is effective.

Duration and frequency of visits.
Specific treatment goals.
Objective measures of treatment effectiveness.
Date of the initial treatment.

Documentation Required

Ongoing-Care Records

For each ongoing-care visit, document the patient's current status, the examination and assessment, the treatment delivered, and the response to treatment. Records must support continued corrective care and the requested frequency and duration.

Review the chief complaint and changes since the last visit, including a relevant system review.
Examine the spinal area involved in the diagnosis and assess change in condition since the prior visit.
Record treatment effectiveness, treatment provided that day, and proposed treatment frequency, duration, and anticipated session length.

Billing Rule

Service Outside Medicare Chiropractic Benefit

Medicare chiropractic coverage extends only to manual manipulation of the spine to correct a documented subluxation. Other services furnished or ordered by a chiropractor are outside this Medicare chiropractic benefit.

Do not treat the presence of a chiropractic service or CMT code alone as establishing coverage.
Coverage requires documented subluxation and manipulation of one or more spinal regions.

Denial Risk

No Qualifying Neuromusculoskeletal Condition

Denial risk exists when the patient does not have a significant neuromusculoskeletal condition requiring treatment, the manipulation lacks a direct therapeutic relationship to that condition, or recovery or functional improvement is not reasonably expected.

Establish the qualifying condition and the therapeutic relationship between the condition, subluxation, and requested manipulation.
Do not request care that is supportive or non-skilled without evidence of expected clinical improvement.

Denial Risk

Insufficient Subluxation Evidence

Denial risk exists when the record does not establish subluxation as the primary diagnosis, lacks x-ray or adequate physical-examination evidence, or fails to identify the precise spinal level.

Physical-examination documentation must include two of the four required findings.
One physical-examination finding must be asymmetry/misalignment or range-of-motion abnormality.
Specify the affected spinal level and the spinal region(s) to be manipulated.

Denial Risk

Maintenance Therapy

Maintenance therapy is not medically reasonable or necessary under the Medicare program. Denial risk exists when further clinical improvement cannot reasonably be expected and treatment has become supportive rather than corrective.

Document ongoing change, treatment effectiveness, objective outcomes, and a reasonable expectation of further improvement.
Do not characterize continuous care as corrective when the record supports only maintenance or care dependence.

Denial Risk

Non-Neuromusculoskeletal Indication

Chiropractic manipulation requested for a non-neuromusculoskeletal condition is not medically necessary and is subject to denial.

Identify the qualifying neuromusculoskeletal condition and its direct relationship to the subluxation and manipulation.
Do not use spinal manipulation as treatment for an indication outside the neuromusculoskeletal scope.

Denial Risk

Incomplete Medical Necessity Documentation

Incomplete or poor provider records may result in denial or limitation of care. Submit complete clinical findings and demonstrate the need for skilled, medically necessary care with measurable outcomes, including pain or activities-of-daily-living measures when relevant.

Document full clinical findings rather than relying on an incomplete diagnosis or treatment label.
Explain why skilled chiropractic care is required and why the requested dosage is appropriate for the patient's specific clinical needs.
Include objective outcome tools and relevant pain or activities-of-daily-living measures to support continued care.
Address contraindications or the need for referral when applicable.

Denial Risk

Insufficient Ongoing-Care Documentation

Denial risk exists when ongoing records do not show interval change, treatment effectiveness, the treatment provided, or the proposed frequency and duration. Continued care requests must clearly demonstrate the medical necessity and reasonableness of further treatment.

Document review of the chief complaint and changes since the last visit.
Record examination of the involved spinal area and assessment of change in condition.
Describe treatment delivered on the date of service and the patient's response or treatment effectiveness.
State the proposed frequency, duration, and anticipated treatment-session length.

Improvement in, or arrest of progression, of the patient's condition.

Acute

DefinitionA condition involving a new injury.

DeterminationThe new injury is determined by x-ray or physical examination.

Policy wordingA patient's condition is considered acute when the patient is being treated for a new injury.

Maintenance therapy

DefinitionCare that becomes supportive rather than corrective when further clinical improvement cannot reasonably be expected from continuous ongoing care.

Care characterMaintenance therapy is supportive rather than corrective.

Medical-necessity statusMedicare chiropractic maintenance therapy is not considered medically reasonable or necessary.