Maintenance/Custodial Care
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This policy governs coverage determinations for in‑office maintenance or custodial care delivered by chiropractors, physical therapists, and occupational therapists, and applies to in‑ and out‑of‑network programs where utilization review decisions about benefit coverage are made.
No material clinical or coverage changes in this revision.
Coverage Determinations
Not Medically Necessary
Policy coverage determination
See Description for specific examples that qualify as maintenance/custodial care (listed in policy Description).
Coverage stance
Policy conclusion based on evidence review
The evidence is limited and very low quality; additional research is needed.
This policy does not apply to routine preventive screening services defined by national preventive care guidelines. Out of scope services include preventive screening measures as described by the U.S. Preventive Services Task Force and Medicare Preventive Services.
Maintenance and custodial care are not a covered benefit under this policy. Such care is considered unproven and not medically necessary for conditions typically managed by chiropractors, physical therapists, and occupational therapists, and therefore may be denied coverage.
Services meeting any of the following descriptions are excluded as maintenance/custodial care: treatment intended to prevent disease or promote general health; scheduled regimes at regular intervals to maintain optimum health; services performable by non‑skilled persons (for example, passive range‑of‑motion exercises or distribution of educational pamphlets); post‑course care when the condition is symptomatically or functionally stationary intended only to preserve current status; interventions aimed solely at improving physical performance (endurance, strength, distance, proprioception); biomechanical goals without achievable therapeutic outcomes (e.g., sagittal curve correction absent operant goals); general fitness programs; diversionary or motivational activities; and services provided solely for patient comfort or convenience.
The rationale for excluding maintenance/custodial care is that the role of such ongoing care has not been established in the scientific literature. There is insufficient evidence that maintenance or custodial programs produce meaningful improvements in health outcomes such as prevention of recurrence or sustained optimal health; accordingly, maintenance/custodial care is considered unproven and not medically necessary.
Provider Requirements and Actions
Prior authorization applies for utilization review determinations
This policy applies to utilization review determinations for in‑office services; providers should expect prior authorization review when benefit coverage decisions are required for ongoing in‑office care.
Prior authorization / patient payment responsibility for elective maintenance care
Maintenance/custodial care is not a covered benefit; if a patient elects non‑covered maintenance care the patient may be required to sign a Billing Acknowledgement Form and assume financial responsibility prior to receiving care.
Document clinical improvement and therapeutic goals to support medical necessity
Document that services meet medical necessity by showing active, improving clinical status and specific therapeutic or rehabilitative goals rather than ongoing care to preserve a stable condition.
- Include objective evidence of improvement or expected functional gains and a clear course‑of‑care plan with measurable goals.
- Avoid documentation that indicates treatment is intended solely to maintain current symptoms or provided for comfort/convenience.
Post‑treatment options: discharge, home care, return‑for‑worsening guidance
When maximum improvement has been reached or complaints have resolved, discharge with home‑care recommendations or advise return only for worsening symptoms; maintenance care is elective and not covered.
- Offer home‑care instructions on discharge.
- Advise the patient to return if symptoms noticeably worsen despite self‑care.
Document active, improving clinical status to show service is not maintenance/custodial
Explicitly document that the service is not maintenance/custodial care by demonstrating an active, improving clinical status and specifying therapeutic/rehabilitative goals tied to measurable outcomes.
- Record progress toward specific goals (pain reduction, increased function) and expected continued improvement.
- Do not document treatment as intended to maintain current condition or for general fitness.
Billing acknowledgement required for elective maintenance care
If a patient elects maintenance/custodial care (a non‑covered benefit), obtain a signed Billing Acknowledgement Form prior to providing care where required; the form indicates the patient assumes financial responsibility (not required in NJ).
Services defined as maintenance/custodial care may be denied
Services that meet the policy definition of maintenance or custodial care are considered unproven and not medically necessary and therefore may be denied; include this risk in patient communications and claims documentation.
Denial risk for maintenance/custodial care — avoid billing/documenting as maintenance
There is a denial risk when services are billed as maintenance/custodial care because such care is considered unproven and not medically necessary; providers should avoid billing or documenting care as maintenance when clinical improvement is ongoing.
- Maintenance defined by the policy includes care intended to maintain or prevent deterioration, services performable by non‑skilled persons, and treatment given when condition is stationary.
- Billing as maintenance may prompt utilization review denial as not medically necessary.
Key Definitions
Background and Context
Maintenance (secondary or tertiary prevention) refers to ongoing care delivered after an initial course of treatment with the intent to prevent recurrence or to maintain an achieved health status. Definitions vary across professions, but commonly include periodic in‑office visits when symptoms are stable or no further improvement is expected, routines designed to preserve current function, and interventions intended to prevent decline rather than to produce additional therapeutic gain.
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