Currentsierra health and lifePolicy 496

Medicare Chiropractic (CMT) Services — Coverage Criteria

Defines medical necessity, documentation, and coverage criteria for chiropractic manipulative treatment (CMT) under Medicare for Sierra Health and Life members; applies to providers requesting payment for chiropractic spinal manipulation.

Policy Summary

Payersierra health and life

PolicyMedicare Chiropractic (CMT) Services — Coverage Criteria

Policy CodePolicy 496

Change TypeNo material changes

Effective DateNov 13, 2024

Next Review Date

Key ActionSubmit prior authorization with documentation demonstrating subluxation (x-ray or physical exam), specified level, treatment plan, and objective outcome measures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CPT codes listed for CMT (spinal regions)

2Physical exam criteria required (must include asymmetry or ROM abnormality)

1Primary diagnosis required: subluxation

Initial + ongoingDocumentation: initial vs ongoing

Coverage and Medical Necessity Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medical necessity criteria

Chiropractic care is considered medically necessary when ALL of the following are met:

Medical necessity general: Patient has a significant neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered have a direct therapeutic relationship to the condition with reasonable expectation of recovery or improved function.

Primary diagnosis must be subluxation of the spine demonstrated by x-ray or physical examination; the precise level of the subluxation must be specified by the chiropractor.

Physical exam criteria for subluxation: When subluxation is demonstrated by physical examination, TWO of the following FOUR criteria are required, and ONE must be asymmetry/misalignment OR range of motion abnormality: (1) pain/tenderness (location, quality, intensity), (2) asymmetry/misalignment identified on a sectional or segmental level, (3) range of motion abnormality, (4) tissue/tone changes of contiguous or associated soft tissues.

Documentation requirements for initial course: Initial course requests must include relevant personal and family history; description of present illness (symptoms with onset, duration, intensity, frequency, location, radiation, mechanism of trauma, aggravating/relieving factors, prior interventions); musculoskeletal/nervous system evaluation; primary diagnosis of subluxation with level specified; and a treatment plan specifying level of care (duration/frequency), specific treatment goals, objective outcome measures, and date of initial treatment.

Planned manipulation: Manual manipulation of one or more spinal regions is planned.

Care beyond initial course: Requests for continued care must document review of chief complaint and changes since last visit, focused examination of the involved spinal area, assessment of change and treatment effectiveness, and documentation of treatment performed on the day of visit; ongoing care is reviewed for medical necessity and reasonableness.

Exclusions / Not medically necessary: Maintenance therapy (care that is continuous and supportive when further clinical improvement cannot reasonably be expected) and chiropractic manipulation for non-neuromusculoskeletal conditions are not medically necessary under Medicare.

Chiropractic manipulative treatment (CMT) is covered with criteria when all medical necessity requirements are met. Specifically, the patient must have a significant neuromusculoskeletal condition requiring treatment and the manipulative services must have a direct therapeutic relationship to that condition with reasonable expectation of recovery or improved function. The patient must have a primary diagnosis of subluxation of the spine demonstrated by x‑ray or physical examination, the chiropractor must specify the precise level of subluxation, and manual manipulation of one or more spinal regions must be planned.

Requests for care beyond the initial course must document continued medical necessity and reasonableness, including review of the chief complaint and changes since the last visit, focused spinal examination with assessment of change and treatment effectiveness, and documentation of treatment provided on the day of service. All ongoing care is reviewed by an Optum clinical specialist and determinations are subject to benefit limits and applicable regulations.

Under Medicare rules applied by this policy, maintenance therapy is not considered medically reasonable or necessary. Maintenance therapy is continuous ongoing care when further clinical improvement cannot reasonably be expected and treatment becomes supportive rather than corrective; such services are excluded from coverage.

Additionally, chiropractic manipulation for non‑neuromusculoskeletal conditions is considered not medically necessary and is excluded from coverage under this policy.

Provider Requirements, Prior Authorization, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient chiropractic and rehabilitation services beyond initial evaluation and treatment when benefits or plan rules indicate prior authorization is needed. Requests for the initial course of treatment and any care beyond the initial course must be submitted for review to determine medical necessity using InterQual® Outpatient Rehabilitation & Chiropractic criteria.

Applies when plan or benefit language requires prior authorization
All ongoing care is reviewed by an Optum clinical specialist provider

Step Therapy

This policy does not impose step therapy requirements. There are no mandated trials of alternative therapies specified as a prerequisite to authorization under this policy.

Documentation Required

Required Documentation for Authorization Requests

Complete documentation is required to support any authorization request. Use InterQual® criteria and include clinical records that demonstrate subluxation (by x-ray or documented physical exam) and evidence of treatment effectiveness for continuation requests.

Initial course requests must include: demonstration of subluxation (x-ray or physical exam with ≥2 of 4 criteria, one being asymmetry/misalignment or range-of-motion abnormality); relevant personal and family history; detailed present illness (onset, duration, intensity, location, radiation, aggravating/relieving factors, prior interventions); musculoskeletal/neurologic exam; primary diagnosis identifying level of subluxation; treatment plan with level of care, duration/frequency, specific goals, objective outcome measures, and date of initial treatment
Requests for care beyond the initial course must include: review of chief complaint and changes since last visit; focused spine exam and assessment of change since prior visit; evaluation of treatment effectiveness; documentation of treatment provided on the day of visit
Incomplete or inadequate records (e.g., missing exam findings, absent objective outcome measures, or no documentation of response to prior treatment) may result in denial or request for additional information

Denial Risk

Denial Triggers

Denials may be triggered by lack of clinical documentation, failure to demonstrate subluxation per criteria, absence of measurable treatment goals or objective outcome measures, or lack of documented improvement when requesting ongoing care.

Missing x-ray or required physical exam findings demonstrating subluxation
No treatment plan with duration, frequency, goals, or objective measures
Insufficient evidence of improvement or continued medical necessity for care beyond the initial course
Incomplete provider records or failure to submit requested additional information

Definitions

Subluxation definition

DefinitionA motion segment in which alignment, movement integrity, and/or physiological function of the spine are altered while joint contact remains intact; may be demonstrated by x-ray or physical examination.

Demonstration requiredSubluxation must be demonstrated by x-ray or by physical examination to meet Medicare-based medical necessity criteria.

Clinical contextPatient condition may be considered acute when treated for a new injury as determined by x-ray or physical examination.

Manual manipulation (CMT) definition

DefinitionChiropractic manipulative treatment (CMT) — a form of manual manipulation to influence joint and neurophysiological function using a variety of techniques; expected to improve or arrest progression of the patient's condition.

ScopeUnder Medicare, coverage is limited to manual manipulation of the spine to correct a demonstrated subluxation; other chiropractic services are not covered.

PurposePlanned manual manipulation must have a direct therapeutic relationship to a significant neuromusculoskeletal condition with expectation of recovery or improved function.

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.

OpenPayer

Medicare Chiropractic (CMT) Services — Coverage Criteria

Coverage and Medical Necessity Criteria

Procedure Codes

Provider Requirements, Prior Authorization, and Billing Guidance

Background

Definitions