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SelectHealth policy table of contents and multiple pediatric-focused coverage policies (Policy #584, #663, #696, #662) governing coverage criteria, exclusions, and billing codes for chiropractic services in children, inhaled nitric oxide therapy (iNO), intrauterine fetal surgery, and progressive adolescent idiopathic scoliosis for commercial, Medicare, and Medicaid plans.
10/4/23: For Commercial Plan Policy, updated criteria to align with requirements for these services outlined in plan documents.
8/27/25: Added 'Pericardial teratoma' as a qualifying condition for intrauterine fetal surgery coverage (Policy #696).
Scope: This document is a multi-policy compilation covering pediatric chiropractic services, inhaled nitric oxide (iNO) therapy, intrauterine fetal surgery, and progressive adolescent idiopathic scoliosis (AIS). Payer: Select Health (Commercial), Select Health Medicare (CMS), and Select Health Community Care (Medicaid). Policy numbers: 584 (Chiropractic Services for Children), 663 (Inhaled Nitric Oxide Therapy), 696 (Intrauterine Fetal Surgery), and 662 (Progressive Adolescent Idiopathic Scoliosis). Effective/implementation date and review dates: overall effective/implementation dates and recent review information per policies — Chiropractic Policy #584 Implementation Date 5/9/16; policy dates summary shows Effective: 2016-05-09, Last review: 2024-08-13, Next review: 2025-08-27. Status: CURRENT. Concise description: consolidated coverage criteria, exclusions, billing/coding guidance, and prior authorization/documentation rules for the listed pediatric services across Commercial, Medicare, and Medicaid plans.
Chiropractic Services for Children - Commercial Plan & CHIP
Coverage summary and conditional coverage by age group:
ALL of the following
For children ages 9 to 12, coverage allowed when ALL of the following are met:
Chiropractic Services - Exclusions
Select Health does not provide chiropractic benefits in the following circumstances:
ALL of the following
Age and prior therapy documentation for chiropractic (ages 9-12)
For children ages 9–12, document that the child has a neuromusculoskeletal disorder causing significant and persistent disability and that other conservative therapies (for example, stretching, heat/ice, over‑the‑counter analgesics) have been tried and failed to relieve symptoms.
Experimental/investigational exclusions
Claims for chiropractic services for children age 8 and under are considered experimental/investigational and may be denied; the policy states services for children ages 8 and under are not provided due to lack of evidence of efficacy or safety.
Inhaled Nitric Oxide (iNO) Therapy - Commercial Plan & CHIP
Select Health considers iNO proven and medically necessary for the following clinical circumstances:
Medical director review for extended iNO use
Medical director review is required for inhaled nitric oxide (iNO) use beyond 14 days. iNO is considered medically necessary without review for up to 14 days when oxygen desaturation has resolved; use beyond 14 days requires medical director review.
Experimental/investigational exclusions
iNO is considered experimental and investigational for all indications other than the specified clinical circumstances (PPHN/hypoxic respiratory failure, certain postoperative pulmonary hypertension management, and diagnostic vaso‑reactivity assessment) and may be denied when used for non‑specified indications.
Intrauterine Fetal Surgery - Commercial Plan & CHIP
Covered at an approved facility for specified fetal conditions when criteria met:
Intrauterine fetal surgery billing
Covered when criteria are met; bill the CPT/HCPCS codes listed for the specific procedure performed.
Experimental/investigational exclusions
Intrauterine fetal procedures that do not meet the listed coverage criteria (for example, procedures for conditions not listed or not meeting gestational/ severity criteria) are considered experimental/investigational and may be denied.
Progressive Adolescent Idiopathic Scoliosis (AIS) - Commercial Plan & CHIP
Coverage stance for fusionless and posterior dynamic devices:
ALL of the following
Code use and specification
When reporting code 22899 (unlisted procedure, spine), specify the procedure (for example, vertebral body stapling or implantation of a posterior dynamic distraction device) to support claim adjudication.
Experimental/investigational exclusions
Posterior dynamic deformity correction devices (e.g., ApiFix/MID‑C) and anterior vertebral body tethering (VBT) are considered experimental/investigational for progressive AIS and may be denied.
| 98940 | Chiropractic manipulative treatment (CMT); spinal, one or two regions |
| 98941 | Chiropractic manipulative treatment; spinal, three to four regions |
| 98942 | Chiropractic manipulative treatment; spinal, five regions |
| 98943 | Chiropractic manipulative treatment; extraspinal, one or more regions |
| 97140 | Manual therapy techniques; 1 or more regions, each 15 minutes |
| 97161 | Physical therapy evaluation: low complexity |
| 97162 | Physical therapy evaluation: moderate complexity |
| 97163 | Physical therapy evaluation: high complexity |
| 97164 | Re-evaluation of physical therapy established plan of care |
| 97010 | Hot or cold packs |
| 97012 | Traction, mechanical |
| 97014 | Electrical stimulation (unattended) |
| 97016 | Vasopneumatic devices |
| 97018 | Paraffin bath |
| G0151 | Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes |
| 53900 | Surface electromyography (EMG) |
| S9131 | Physical therapy; in the home, per diem |
| 94002 | Ventilation assist and management; initiation inpatient/observation, initial day |
| 94003 | Ventilation assist and management; each subsequent day |
| 94004 | Ventilation assist and management; nursing facility, per day |
| 94005 | Home ventilator management care plan oversight, within a calendar month; 30 minutes or more |
| 93463 | Pharmacologic agent administration (e.g., inhaled nitric oxide) including hemodynamic assessment when performed separately |
| 99503 | Home visit for respiratory therapy care |
| 59072 | Fetal umbilical cord occlusion, including ultrasound guidance |
| 59074 | Fetal fluid drainage including ultrasound guidance |
| 59076 | Fetal shunt placement; including ultrasound guidance |
| 59897 | Unlisted fetal invasive procedure, including ultrasound guidance |
| S2400 | Repair; congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero |
| S2401 | Repair, urinary tract obstruction in the fetus, procedure performed in utero |
| S2402 | Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero |
| S2403 | Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero |
| S2404 | Repair, myelomeningocele in the fetus, procedure performed in utero |
| S2405 | Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
| S2409 | Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified |
| S2411 | Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome |
| 0657T | Vertebral body tethering, anterior; 8 or more vertebral segments |
| 0656T | Vertebral body tethering, anterior; up to 7 vertebral segments |
| 20930 | Allograft, morselized or placement of osteopromotive material, for spine surgery only |
| 20936 | Autograft for spine surgery only; local |
| 20931 | Allograft, structural, for spine surgery only |
| 20937 | Autograft for spine surgery only; morselized (through separate skin or fascial incision) |
| 22612 | Arthrodesis, posterior or posterolateral technique, single level; lumbar |
| 20938 | Autograft for spine surgery only; structural bicortical or tricortical |
| 22800 | Arthrodesis, posterior; for spinal deformity, up to 6 vertebral segments (levels) |
| +22842 | Posterior segmental instrumentation; 3 to 6 vertebral segments |
| +22840 | Posterior non-segmental instrumentation (e.g, Harrington rod technique, pedicle fixation across interspace, atlantoaxial transarticular screw fixation, sublaminar ' at C1, facet screw fixation) wiring |
| +22843 | Posterior segmental instrumentation (e.g., pedicle fixation; dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments |
| 22899 | Unlisted procedure, spine [when specified as vertebral body stapling or implantation of a posterior (dynamic) distraction device] |
Medical director review for extended iNO use
Medical director review is required for inhaled nitric oxide (iNO) use beyond 14 days; iNO is considered medically necessary without review for up to 14 days but requires review for durations beyond that threshold.
Age and prior therapy documentation for chiropractic (ages 9-12)
For children ages 9–12, document the neuromusculoskeletal disorder causing significant and persistent disability and that other conservative therapies (e.g., stretching, heat/ice, OTC analgesics) have been tried and failed.
Intrauterine fetal surgery billing
Covered when criteria are met; bill the CPT/HCPCS codes listed for the specific intrauterine procedure performed (see codes list).
Experimental/investigational exclusions
Summary of services likely to be denied as experimental/investigational: chiropractic services for children ≤8; iNO for indications other than the specified uses (PPHN, certain postoperative uses, diagnostic vaso‑reactivity); intrauterine procedures that do not meet the listed criteria; and AIS devices/procedures such as ApiFix and VBT.
Code use and specification
When reporting code 22899, include specification of the unlisted spine procedure (for example, vertebral body stapling or implantation of a posterior dynamic distraction device) to support adjudication.
Background: This is a multi-policy compilation containing separate coverage policies for pediatric chiropractic services (Policy #584), inhaled nitric oxide (iNO) therapy (Policy #663), intrauterine fetal surgery (Policy #696), and progressive adolescent idiopathic scoliosis (Policy #662). These policies outline coverage determinations for Select Health Commercial, Select Health Medicare (CMS), and Select Health Community Care (Medicaid) plans and note that application of criteria depends on the member’s benefit coverage at the time of request.
Applicability notes: Medicare (CMS) coverage determinations override when CMS has adopted a coverage decision; if CMS has not adopted a determination and InterQual criteria are not available, the Select Health Commercial policy applies. Select Health Community Care (Medicaid) policies typically align with State Medicaid policy, including use of InterQual; there may be situations where NCD/LCD or Select Health Commercial policies are used.
| label | value |
|---|---|
| Chiropractic evidence summary | Current evidence for pediatric chiropractic care is limited and low quality; systematic reviews and RCTs show insufficient high-quality evidence supporting efficacy. |
| iNO evidence summary | High-quality evidence indicates no benefit of early iNO in preterm infants <35 weeks for survival or pulmonary morbidity; iNO proven for PPHN and select postoperative uses. |
| Hayes review - The Tether | Evolving Evidence Review. Apr 7, 2022 |
| Hayes review - ApiFix (2020) | Minimally Invasive Deformity Correction System (ApiFix). Nov 20, 2020 |
| Hayes review - ApiFix (2023) | Evidence Analysis Research Brief. Dec 11, 2023 |
Definitions:
PPHN: Persistent pulmonary hypertension of the newborn (used in iNO policy indications).
O/E LHR: Observed-to-expected lung-to-head ratio, used to define severity of pulmonary hypoplasia in congenital diaphragmatic hernia (CDH); criterion for FETO is O/E LHR < 25.0%.
VBT: Vertebral body tethering, a fusionless anterior growth-modulation surgical technique for AIS (described as a nonfusion technique that modulates spinal growth and is considered experimental/investigational for coverage in the AIS policy).
10/4/23: For Commercial Plan Policy, updated criteria to align with requirements for these services outlined in plan documents (Revision History for Policy #584).
8/27/25: Added 'Pericardial teratoma' as a qualifying condition for intrauterine fetal surgery coverage (Policy #696); marked as material change to Section A of Policy #696.