Currentsierra health and lifePolicy 2026T0541W

Manipulative Therapy (OMT/SMT/CMT)

Policy governing coverage and medical necessity of manipulative therapy (including osteopathic, chiropractic, and other manual therapies) for musculoskeletal disorders under Sierra Health and Life/UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

Payersierra health and life

PolicyManipulative Therapy (OMT/SMT/CMT)

Policy CodePolicy 2026T0541W

Change TypeTemplate Update

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify member-specific benefit plan and document indication, prior conservative treatments, and clinical justification when submitting prior authorization.

SourceLink

POLICY UPDATE CHANGES

Template Update noted in Summary of Changes.

MSD focusMSD focus

98925-98929, 98940-98943Referenced codes

S8990Maintenance HCPCS

9,211Rubinstein meta-analysis N

insufficientMaintenance evidence

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.

Coverage Criteria for Manipulative Therapy

inv-01: Covered Indications — Covered when ALL of the following are met

Covered when ALL of the following are met

Basic coverage: Manipulative Therapy is proven and medically necessary for treating Musculoskeletal Disorders (MSDs).

MSDs are injuries or conditions originating from joints, muscles, ligaments, discs, or other soft tissues in the spine or limbs that produce clinically relevant symptoms and functional limitations.

inv-02: Not Medically Necessary / Unproven Indications — Not covered (Unproven) when ANY of the following apply

Not covered (Unproven) when ANY of the following apply

Unproven indications: Manipulative Therapy is unproven and not medically necessary for non-musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, internal organ disorders), prevention/maintenance/custodial care, craniosacral therapy, temporomandibular joint disorder (TMJ/TMD), scoliosis, and manipulative services using nonstandard techniques (e.g., applied kinesiology, NUCCA).

Examples listed in policy; refer to Manipulation Under Anesthesia policy for that service.

inv-03: Covered with clinical criteria (condition- and context-specific) — Coverage supported when evidence and context align (examples from literature):

Coverage supported when evidence and context align (examples from literature):

Acute low back pain: SMT/OMT may be considered for acute low back pain (≤6 weeks) when documentation supports a trial of conservative care; RCT evidence shows modest short-term improvements in pain and function.timeframe ≤6 weeks

Moderate-quality evidence for short-term benefit (Paige et al. 2017).

Chronic non-specific neck pain: Manipulative therapies may be considered for chronic non-specific neck pain (>3 months) as part of a multimodal plan including exercise; systematic reviews report reduced pain and disability though heterogeneity and variable quality exist.duration >3 months

Findings affected by heterogeneity and low/very low quality in some reviews (Liu et al., Dal Farra et al.).

Shoulder conditions:

inv-04: Evidence-aligned coverage conditions — Coverage for manual therapy or spinal manipulation may be considered when the following evidence-aligned conditions are met

Coverage for manual therapy or spinal manipulation may be considered when the following evidence-aligned conditions are met

Baseline requirements: Patient has a documented musculoskeletal condition with baseline pain or functional impairment and prior appropriate conservative measures attempted as indicated (e.g., exercise, splinting, medication). The treatment plan must specify the technique, body region(s), frequency, and measurable goals for improvement.

Derived from trials where manual therapy was adjunct to or compared with conservative care.

Short-term use supported by evidence: Manual therapy/spinal manipulation may be authorized for short-term relief of pain and function for conditions where RCTs or meta-analyses show benefit (for example: knee OA when combined with exercise; ankle/foot disorders with proprioceptive training; cervicogenic headache), recognizing most trials report primarily short-term outcomes.

Supported by RCTs and systematic reviews showing short-term improvements; long-term benefit uncertain.

Maintenance care conditions: Ongoing maintenance manipulative therapy should be considered only for patients with documented favorable initial response to a defined course of care and when psychological subgrouping and expected benefit are documented; frequency and outcomes must be tracked and reassessed because evidence for long-term preventive benefit is inconsistent and subgroup-dependent.

inv-05: Maintenance Chiropractic Care (MC) — Covered when ALL of the following are met

Covered when ALL of the following are met

MC-eligibility: Patient has recurrent or persistent non-specific low back pain AND had an early favorable response to an initial course of chiropractic/manipulative treatment AND documentation demonstrates patient-level benefit (e.g., fewer days with bothersome low back pain) that is tracked and used to justify ongoing care.documented early favorable response; benefit tracked (days with bothersome LBP)

Eklund et al. showed subgroup-specific effects and a 12.8-day reduction overall that did not meet prespecified clinically meaningful thresholds; subgroup (DYS) showed larger benefit.

inv-06: Visceral Manipulation — Covered when ALL of the following are met

Covered when ALL of the following are met

VisceralManipulation-Adjunct: Visceral manipulation may be considered only as an adjunct to standard physiotherapy when the member has had failure of or incomplete response to standard care AND the request documents a defined treatment plan with measurable goals and reassessment; RCT evidence does not support short-term improvement from adding visceral manipulation to standard care.demonstrated failure or inadequate response to standard care

Panagopoulos et al. (2015) found no short-term benefit; one trial reported less pain at 52 weeks but overall short-term outcomes were unchanged.

inv-07: Craniosacral Therapy (CST) — 1 top-level node

CST-Unproven: Craniosacral therapy (CST) is considered unproven and not medically necessary due to insufficient high-quality evidence demonstrating clinically meaningful benefit.none

Meta-analyses (e.g., Amendolara et al. 2024) of RCTs (24 RCTs, 1,613 participants) found no overall significant effects; study limitations and bias limit interpretability.

inv-08: SMT/OMT for Non-Musculoskeletal Disorders — 1 top-level node

SMT-NonMSK-NotSupported: Spinal manipulative therapy (SMT) and other manual therapies are not supported for the treatment or prevention of non-musculoskeletal disorders (including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, migraine) based on higher-quality RCTs and systematic reviews; such uses are considered not medically necessary.none

Global Summit synthesis (Côté et al. 2021) and rapid evidence reviews found no credible evidence of clinically relevant immune or organ-system effects.

inv-09: Coverage stance for Craniosacral Therapy — Summary of evidence-based coverage stance

Summary of evidence-based coverage stance

Overall evidence conclusion: Craniosacral therapy is considered unproven with insufficient high-quality evidence to support efficacy for musculoskeletal or non-musculoskeletal indications; systematic reviews and meta-analyses report no reliable clinical benefit and substantial study limitations.

Multiple recent systematic reviews/meta-analyses (2020–2024) found no consistent benefit; methodological limitations and bias are common.

This policy addresses Manipulative Therapy (including osteopathic manipulative treatment, spinal manipulative therapy, chiropractic manipulative treatment, and related manual therapies) as applied to musculoskeletal disorders (MSDs). Coverage is limited to care that is medically necessary for MSDs; therapies intended to treat non‑musculoskeletal conditions, to provide preventive or custodial maintenance without demonstrated clinical benefit, or that use nonstandard techniques are considered unproven and not medically necessary. Detailed exceptions and exclusions are described below.

The evidence is insufficient to support the use of manual therapy or spinal manipulation as a primary corrective treatment for adolescent or adult idiopathic scoliosis. Systematic reviews and available prospective studies have methodological limitations (small samples, high risk of bias, inconsistent outcome reporting) and do not establish reliable benefit in curve correction or long‑term outcomes; therefore such interventions should not be considered proven primary corrective therapy for idiopathic scoliosis.

Preventive manipulative treatment intended to improve immune function or to prevent infectious disease outcomes is excluded due to insufficient and inconsistent evidence. Systematic reviews and rapid evidence assessments found no credible clinical evidence that spinal manipulation confers clinically meaningful immune or infectious‑disease prevention benefits.

Claims that spinal manipulation can treat or prevent infectious diseases or ‘enhance immunity’ are unsupported by credible scientific evidence and therefore are excluded. Rapid evidence reviews and systematic analyses found no demonstrated clinically relevant immune effects attributable to spinal manipulation.

International guidance and systematic reviews do not recommend spinal manipulation or craniosacral therapy for infants or for non‑musculoskeletal pediatric conditions (for example, infantile colic, asthma, otitis media, or neurodevelopmental disorders). Manipulation and CST should not be used in infants or children for non‑MSD indications given lack of demonstrated benefit and guideline recommendations against these applications.

When applying this policy, the member specific benefit plan document governs. If the member’s plan terms differ from this policy, the plan language and any applicable federal or state mandates take precedence and should be verified prior to authorization or payment.

Except for musculoskeletal disorders, manipulative therapies are considered unproven and not medically necessary. This includes indications such as asthma, otitis media, infantile colic, internal organ disorders, preventive or custodial maintenance care, craniosacral therapy, temporomandibular joint disorder, scoliosis, and services employing nonstandard techniques.

Procedures that claim to correct idiopathic scoliosis through manual therapy or spinal manipulation alone lack convincing, high‑quality evidence. Existing studies are small, uncontrolled, or at high risk of bias, and systematic reviews conclude the evidence is insufficient to support such claims.

Provision of spinal manipulative therapy specifically to prevent infectious disease or to alter immune outcomes is not supported by the available evidence and should be considered not medically necessary when proposed for preventive immune benefit.

Spinal manipulative therapy or osteopathic manipulative treatment is not supported for the treatment or prevention of non‑musculoskeletal disorders (for example: infantile colic, childhood asthma, hypertension, primary dysmenorrhea, migraine). High‑quality and acceptable‑quality randomized trials found no superiority of SMT over sham interventions for these conditions.

Craniosacral therapy (CST) is considered unproven. Recent systematic reviews and meta‑analyses including multiple RCTs conclude CST lacks consistent, reliable clinical benefit for the studied musculoskeletal and non‑musculoskeletal indications; CST should not replace conventional evidence‑based care.

Provider Action Items, Prior Authorization, and Documentation

Billing Rule

Coding and documentation required for OMT/CMT and S8990

Use appropriate billing/coding and include clinical documentation that supports the diagnosis and body regions treated. When billing OMT (98925–98929) or CMT (98940–98943), document the specific body region(s) treated and the medical indication. HCPCS S8990 (maintenance therapy) may only be billed when documentation demonstrates maintenance rather than restorative intent and meets the policy's maintenance criteria.

Support OMT/CMT codes with chart notes specifying regions treated and clinical findings
Do not bill S8990 without documentation that the service is maintenance and meets maintenance criteria noted in policy
Refer to Habilitation and Rehabilitation Therapy policy when using CPT 97140 for manual therapy

Prior Authorization

Prior authorization recommended for scoliosis-related manipulation

Procedure and HCPCS Codes

Covered/Referenced Manipulative Procedure CodesCPT

98925	Osteopathic manipulative treatment (OMT); 1-2 body regions involved.
98926	Osteopathic manipulative treatment (OMT); 3-4 body regions involved.
98927	Osteopathic manipulative treatment (OMT); 5-6 body regions involved.
98928	Osteopathic manipulative treatment (OMT); 7-8 body regions involved.
98929	Osteopathic manipulative treatment (OMT); 9-10 body regions involved.
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.
98943	Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions.

HCPCSHCPCS

S8990

Physical or manipulative therapy performed for maintenance rather than restoration.

Background and Rationale

Manipulative therapies encompass hands‑on techniques (mobilization, manipulation, myofascial release, and related soft tissue techniques) used to address pain and functional impairment in joints, muscles, ligaments, discs and other soft tissues. Evidence from systematic reviews and randomized trials shows modest, generally short‑term improvements in pain and function for some MSDs, but heterogeneity in methods and quality limits conclusions for many indications.

Manipulative Therapy — definition

ScopeIncludes osteopathic manipulative treatment, manipulative and body-based practices, manual therapy, and related physical touch methods used to achieve and maintain patient health.

Clinical purposeUsed to address structural and functional issues of bones, joints, tissues, and muscles to reduce pain and improve function.

Musculoskeletal Disorders (MSDs) — definition

DefinitionInjuries or conditions originating from joints, muscles, ligaments, discs, or other soft tissues in the spine or limbs that produce clinically relevant symptoms (e.g., pain, numbness) and functional limitations.

Policy Revision History

2026-01-01template_updateLatest

Template update recorded in Policy History/Revision Information.

Policy Summary

Payersierra health and life

PolicyManipulative Therapy (OMT/SMT/CMT)

Policy CodePolicy 2026T0541W

Change TypeTemplate Update

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify member-specific benefit plan and document indication, prior conservative treatments, and clinical justification when submitting prior authorization.

SourceLink

On This Page

For shoulder impingement and adhesive capsulitis, exercise is first-line and manual therapy may be added; mobilization techniques can be beneficial for adhesive capsulitis and manual therapy plus exercise may outperform exercise alone for impingement.

used as adjunct to or following exercise

Evidence quality low to moderate with heterogeneity (Steuri et al., Noten et al.).

Elbow, wrist, or hand disorders: Mobilization or manipulation as part of multimodal care may provide short- to intermediate-term pain relief and functional improvement for conditions such as lateral epicondyle pain and carpal tunnel symptom perception.short/intermediate-term outcomes supported

Evidence limited and studies generally low quality (multiple systematic reviews).

Hip and knee osteoarthritis: Manual therapies added to exercise may provide short-term improvements in pain and function for hip and knee osteoarthritis; studies report benefits of manual therapy combined with exercise versus exercise alone.used as adjunct to exercise

Long-term effectiveness is unclear; trials are small with short follow-up (Reza et al., Altinbilek et al., Salamh et al.).

documented early favorable response

Based on Eklund trials indicating subgroup-specific effects and marginal overall clinical meaning.

TMJ/TMD and other limited-evidence indications: For TMJ/TMD and similar indications with limited and heterogeneous evidence, authorize only when conservative care has been tried, trial-level evidence supporting benefit is provided, and time-limited outcome reassessment is planned.conservative care attempted and documented

Multiple small RCTs and reviews highlight small sample sizes and heterogeneity (Al-Moraissi, Dunning et al.).

Prior authorization may be required for use of manipulative therapy to treat idiopathic scoliosis. Given the limited and low-quality evidence for manual therapy and spinal manipulation for scoliosis, requests should include high-quality supporting documentation and will be reviewed case-by-case.

Provide prior conservative care documentation and objective scoliosis measurements (e.g., Cobb angle)
Include study-specific rationale if relying on published protocols (e.g., CLEAR) and explain why conservative care is insufficient

Prior Authorization

Prior authorization: conservative therapy and documented goals required

Prior authorization is recommended when manipulative therapies are requested for knee osteoarthritis, temporomandibular disorders, or related conditions. Approvals should be supported by documentation of prior conservative therapy attempts, clear measurable treatment goals, and evidence that manipulation is intended to restore function.

Document prior conservative treatments (e.g., exercise therapy, pharmacologic measures, splints) and dates/outcomes
State specific, time-limited goals (pain reduction, functional improvement) and planned evaluation points
Provide justification for manipulation as adjunct to, not replacement of, standard care

Prior Authorization

Prior authorization for maintenance manipulative therapy

Maintenance manipulative therapy (long-term/recurring) requires prior authorization and explicit justification. Maintenance care should only be considered for patients with documented early favorable response and ongoing, measurable benefit documented at intervals.

Document initial favorable response to a defined course of restorative treatment
Include psychological subgroup assessment when relevant and record how maintenance is expected to reduce days with bothersome pain or improve function
Specify monitoring plan and measurable outcomes to reassess continued need

Documentation Required

Prior authorization expectations — documentation and evidence

When requesting prior authorization for manipulative therapies, submit indication, prior conservative treatments attempted, and high-quality evidence supporting expected benefit. Lack of supporting evidence for the indication may lead to denial.

Include diagnosis, symptom duration, prior therapies with dates and responses, and clearly stated treatment goals
Attach relevant peer-reviewed literature or guideline recommendations that support the requested intervention
Note that member-specific benefit plans and applicable mandates govern final coverage decisions

Note

Prior authorization and utilization tools — verify member benefits

Coverage and prior authorization requirements are governed by the member-specific benefit plan. UnitedHealthcare (or the payer) may use utilization management tools (e.g., InterQual) to support authorization decisions.

Verify member-specific benefits prior to authorization or billing
Authorizations, denials, and utilization requirements may vary by plan and state/federal mandates

Denial Risk

Denial risk: non‑MSD indications and nonstandard techniques

Do not provide manipulative services for non-musculoskeletal indications or using nonstandard techniques. Requests for manipulation for conditions lacking evidence (infantile colic, asthma, hypertension, prevention of infectious disease, etc.), craniosacral therapy, NUCCA, applied kinesiology, or other nonstandard methods are at high risk for denial.

Claims for non‑MSD indications are deniable due to insufficient evidence
CST and other unproven techniques should not be billed as medically necessary interventions

Step Therapy

Exercise-first approach recommended for shoulder and hip conditions

For conditions where evidence supports an exercise-first approach (e.g., shoulder and hip OA), document that standard exercise-based therapy was attempted before or concurrently with manipulation; manual therapy may be considered adjunctive.

Document exercise programs, duration, adherence, and response
If manual therapy is requested as adjunct, explain incremental benefit expected over exercise alone

Documentation Required

Provide required study documentation when used for justification

When relying on published studies to justify treatment, provide study details (design, sample size, outcomes, adverse events) and explain applicability to the individual member. Low-quality, small, or uncontrolled studies are insufficient by themselves.

Attach full-text references or summaries highlighting relevance to the patient's age, diagnosis, and prior treatment
Clarify why the treatment is expected to produce clinically meaningful benefit for this patient

Documentation Required

Support coding with clinical documentation and MSD indication

Support all procedure codes with clinical documentation that demonstrates a musculoskeletal disorder (MSD) indication, symptom duration, prior therapies, and treatment goals. Services provided for non-MSD indications or using unproven techniques may be denied.

Include diagnosis, symptom onset and duration, prior conservative interventions and responses, and planned measurable outcomes
Reference relevant CPT/HCPCS codes being billed and document how the service meets medical necessity

ExamplesLow back pain, neck pain, shoulder disorders, hip and knee osteoarthritis, extremity tendinopathies and soft-tissue injuries.

Policy scopeManipulative Therapy is considered proven and medically necessary only when used to treat Musculoskeletal Disorders as defined here.

Spinal manipulative therapy (SMT) — definition

DefinitionHands-on therapeutic spinal manipulation intended to improve pain and function, typically delivered for conditions such as acute low back pain and other spine-related disorders.

Evidence summarySystematic reviews/meta-analyses report modest short-term improvements in pain and function for acute low back pain (≤6 weeks) with transient minor musculoskeletal harms.

Contextual noteEffect estimates vary by study quality, manipulation type, and whether SMT was delivered alone or as part of multimodal care.

Osteopathic manipulative treatment (OMT) — definition

DefinitionA set of manual medicine techniques performed by osteopathic practitioners (OMT/OMM) intended to decrease pain and improve function.

Evidence summarySystematic reviews suggest possible short-term benefits for low back and pelvic girdle pain (including pregnancy-related LBP), though studies vary in quality and sample size.

Practice noteOMT trials often include varied techniques and mixed comparators; larger high-quality RCTs are recommended to clarify effects.

Manual therapy / OMT techniques — summary

DefinitionHands-on techniques including mobilization, manipulation, myofascial mobilization, and related soft-tissue techniques used alone or combined with exercise to reduce pain and improve function.

Typical useApplied for extremity and joint conditions (e.g., knee OA) often as an adjunct to supervised exercise or multimodal care.

LimitationsMost trials report short-term benefits; long-term effectiveness is generally unclear due to small sample sizes and short follow-up.

Maintenance care (MC) — short definition

DefinitionOngoing periodic manipulative or chiropractic care provided after an initial favorable response, intended to reduce days with bothersome pain or prevent recurrence.

Intended outcomeReduce future pain days or recurrences for patients with recurrent/persistent low back pain following an initial effective course of care.

Evidence cautionOverall evidence for preventive long-term benefit is inconsistent; subgroup analyses show differential effects by psychological profile.

Maintenance care (MC) — alternate phrasing

Alternate phrasingOngoing, preventive spinal manipulation or chiropractic visits provided after an initial favorable response to care with the intent to reduce future pain days or recurrences.

Eligibility noteMay be considered for patients who demonstrate an early favorable response and when documentation includes subgrouping (e.g., DYS, AC, ID) and tracked outcomes.

Clinical thresholdEvidence indicates clinically meaningful thresholds were not consistently met across trials; benefits vary by subgroup and require documentation to justify continuation.

Craniosacral therapy (CST) — definition

DefinitionA manual therapy technique targeting cranial and sacral structures using gentle manipulative contact intended to influence craniosacral rhythms and related structures.

Evidence summarySystematic reviews and meta-analyses (e.g., 24 RCTs, 1,613 participants) found no consistent significant effects; evidence quality and risk of bias limit conclusions.

Clinical guidanceCST should not replace conventional evidence-based care given lack of reliable demonstrated benefit.

Craniosacral Therapy (CST) — alternate phrasing

Alternate phrasingA gentle manual/osteopathic technique involving light contact to cranial and sacral structures, proposed to affect autonomic function and treat diverse conditions, but current evidence is insufficient to support clinical efficacy.

Diagnostic reliabilitySystematic reviews report poor reliability of CST-based diagnostic methods and high risk of bias across trials.

Safety noteWhile likely benign as a complementary approach, CST should not be used in place of conventional medical care due to lack of demonstrated benefit.

Non-standard manipulative techniques — examples

ExamplesApplied kinesiology; National Upper Cervical Chiropractic Association (NUCCA) techniques; neural organizational technique (NOT).

Evidence notePublished peer-reviewed literature was not identified for these non-standard techniques in the policy review.

Coverage implicationServices using these non-standard techniques are considered unproven and may be denied as not medically necessary.

Referenced evidence — study types

Types of studies citedSystematic reviews, randomized controlled trials (RCTs), and health technology assessments (HTAs) are included in the reference list.

Scope of evidenceCited literature spans meta-analyses, multi-center RCTs, pragmatic trials, and systematic reviews covering SMT, OMT, CST, and other manual therapies.

Use in policyThese study types underpin evidence summaries and coverage positions throughout the policy (benefit for MSDs, unproven indications, and CST conclusions).