Currentsierra health and lifePolicy 496

Medicare Chiropractic Services (Chiropractic Manipulative Treatment — CMT)

Policy governing Medicare-covered chiropractic manipulative treatment (CMT) for spinal subluxation and documentation/authorization requirements for providers and reviewers. Affects Medicare beneficiaries and providers delivering chiropractic services under Sierra Health and Life/Optum UM.

Policy Summary

Payersierra health and life

PolicyMedicare Chiropractic Services (Chiropractic Manipulative Treatment — CMT)

Policy CodePolicy 496

Change TypeNo material changes

Effective DateFeb 11, 2026

Next Review DateN/A

Key ActionSubmit requests for outpatient CMT (CPT 98940-98942) with documentation meeting Medicare/InterQual criteria including required clinical findings and treatment plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

98940-98942CPT codes listed for CMT

CMS Ch.15Primary regulatory source

InterQualSupplemental criteria

Initial + BeyondDocumentation split

Coverage Criteria for Chiropractic Manipulative Treatment (CMT)

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Initial medical necessity criteria

Covered when ALL of the following are met

Medicare chiropractic medical necessity: 1) Patient has a 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 (CMS Medicare Benefit Policy Manual, Chapter 15). 2) Primary diagnosis is spinal subluxation demonstrated by x-ray or physical examination. 3) The precise level of the subluxation is specified by the chiropractor. 4) Manual manipulation of one or more spinal regions is planned.

Based on Medicare Benefit Policy Manual Chapter 15 and associated documentation requirements

Care beyond initial course

Continuation of care covered when ALL of the following are provided

Ongoing care justification: Documentation shows medical necessity and reasonableness of further chiropractic treatment, including: review of chief complaint and changes since last visit; focused physical examination of the involved spinal area with assessment of change since prior visit; evaluation of treatment effectiveness using objective measures; documentation of treatment provided on the day of visit; and a treatment plan specifying frequency, duration, and anticipated length of ongoing sessions.

All ongoing care is reviewed by an Optum clinical specialist and is subject to benefit limits and regulations

Not medically necessary / Exclusions

Not covered conditions: Chiropractic maintenance therapy (continuous ongoing care that is supportive rather than corrective) and chiropractic manipulation for non-neuromusculoskeletal conditions are not medically necessary.

Under the Medicare program, maintenance therapy is not considered medically reasonable or necessary

Chiropractic manipulation for non‑neuromusculoskeletal conditions is not covered. The policy requires that the patient have a significant neuromusculoskeletal condition and that manipulative services be directly therapeutic with a reasonable expectation of recovery or improved function; procedures provided for conditions outside that scope do not meet medical necessity criteria and are excluded from coverage. Additionally, maintenance therapy — defined as continuous ongoing care that is supportive rather than corrective, where further clinical improvement cannot reasonably be expected — is not covered under Medicare.

Under the Medicare program, chiropractic maintenance therapy is not considered medically reasonable or necessary. The policy follows Medicare Benefit Policy Manual Chapter 15 guidance that when treatment becomes supportive rather than corrective because further clinical improvement cannot reasonably be expected, ongoing care is maintenance and is not a covered benefit.

Provider Requirements, Documentation & Prior Authorization

Prior Authorization

Prior Authorization / Medical Necessity

Requests for outpatient chiropractic manipulation therapy (CMT) must meet Medicare and InterQual criteria and include required clinical documentation. Prior authorization may be required; submit full clinical records with the request to avoid delays.

Prior authorization/medical necessity must reference InterQual and Medicare criteria
Include complete clinical records with prior authorization requests

Denial Risk

Provider Action — Attention Required

Submit all required documentation with the initial request and for ongoing care. Incomplete or poor records may result in denials or delayed decisions. Ensure records clearly demonstrate the need for skilled chiropractic services and measurable outcomes where applicable.

Incomplete or inadequate records may lead to inappropriate denials
Provide complete, legible clinical notes and objective outcome data

Documentation Required

Initial Course Documentation Requirements

For an initial course of chiropractic treatment, documentation must demonstrate a subluxation (via x-ray or physical exam) and include a comprehensive evaluation and treatment plan.

Subluxation documented by x-ray OR physical exam (if by exam, ≥2 of the 4 criteria required, one must be asymmetry/misalignment or range of motion abnormality): pain/tenderness; asymmetry/misalignment; range of motion abnormality; tissue/tone changes
Relevant personal and family health history
Detailed present illness: symptoms related to level of subluxation, quality/character, mechanism of trauma, onset/duration/intensity/frequency/location/radiation, aggravating/relieving factors, prior interventions/medications
Musculoskeletal/nervous system physical exam
Primary diagnosis must state subluxation and level (or descriptive term)
Treatment plan with recommended level of care (duration/frequency), specific treatment goals, objective outcome measures, and date of initial treatment

Documentation Required

Documentation for Ongoing Care

For care beyond the initial course, provide documentation demonstrating medical necessity and reasonable expectation of benefit.

Review of chief complaint and changes since last visit (include system review if relevant)
Focused exam of the spinal area involved and assessment of change since prior visit
Evaluation of treatment effectiveness with measurable outcomes
Documentation of treatment provided on the day of visit
Planned treatment frequency, duration, and anticipated length of sessions
All ongoing care is subject to review by an Optum clinical specialist and applicable benefit or regulatory limits

Definitions

Subluxation — definition

DefinitionA motion segment in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.

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

Clinical contextA patient’s condition is considered acute when being treated for a new injury as determined by x-ray or physical examination.

Manual manipulation (CMT) — definition

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

ScopeManual manipulation (CMT) refers specifically to techniques intended to affect joint and neurophysiological function of the spine.

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 Services (Chiropractic Manipulative Treatment — CMT)

Coverage Criteria for Chiropractic Manipulative Treatment (CMT)

Relevant CPT Codes for CMT

Provider Requirements, Documentation & Prior Authorization

Background and Scope

Definitions