CurrentUnitedHealthcarePolicy CS076NJ.O

Manipulative Therapy (for New Jersey Only)

UnitedHealthcare Community Plan medical policy governing coverage and medical necessity of Manipulative Therapy (including OMT, CMT, manual therapy) for members in New Jersey; defines covered indications (musculoskeletal disorders), non-covered indications, definitions, applicable CPT/HCPCS codes (reference), and summarizes clinical evidence.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for New Jersey Only)

Policy CodePolicy CS076NJ.O

Change TypeDefinitions added; references updated; link removed

Effective DateJuly 1, 2025

Next Review Date

Key ActionProvider must document that manipulative therapy is being used to treat a musculoskeletal disorder with clinically relevant symptoms and functional limitations; documentation should support medical necessity versus maintenance/ custodial care.

SourceLink

POLICY UPDATE CHANGES

Removed reference link to Diagnostic Spinal Ultrasonography (for New Jersey Only) and Neuropsychological Testing Under the Medical Benefit (for New Jersey Only) (retired Sep. 1, 2025).

Added definition of 'Upledger Technique'.

Updated Clinical Evidence and References sections to reflect the most current information and archived previous policy version CS076NJ.N.

1State-specific policy (New Jersey only)

1Covered indication category: Musculoskeletal Disorders

>=6Not-covered examples listed

1Definitions modified

Coverage Summary

This UnitedHealthcare Community Plan policy applies to the State of New Jersey only and governs coverage and medical necessity for Manipulative Therapy (including OMT, CMT, and manual therapy). The policy takes a mixed coverage stance: manipulative therapy is covered (medically necessary) for Musculoskeletal Disorders (MSDs) when documentation and criteria are met, but not covered / unproven for many other indications.

Headline categories: Covered — musculoskeletal disorders originating from joints, muscles, ligaments, discs, or other soft tissues of the spine or limbs that produce clinically relevant symptoms and functional limitations. Not covered / unproven — non-musculoskeletal indications (e.g., asthma, otitis media, infantile colic, visceral/internal organ disorders), prevention/maintenance/custodial care, craniosacral/Upledger Technique, temporomandibular joint disorder, scoliosis, and manipulative services using nonstandard techniques (e.g., applied kinesiology, NUCCA).

Key Policy Facts

Policy ScopeState of New Jersey only

Policy NumberCS076NJ.O

Effective DateJuly 1, 2025

Coverage stancemixed

Primary covered indication categoryMusculoskeletal Disorders (MSDs)

Medical-Necessity Criteria

Medically Necessary (Covered) Indications

Covered when ALL of the following are met:

ALL of the following

Manipulative Therapy is used to treat Musculoskeletal Disorders (MSDs) 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 (e.g., ability to perform daily activities).

Not Medically Necessary (Unproven / Excluded) Indications

Manipulative Therapy is unproven and not medically necessary for ALL other indications, including but not limited to:

Excluded/Not Medically Necessary Indications

Non-Musculoskeletal Disorders (e.g., asthma, otitis media, infantile colic, internal organ disorders, etc.)

Background & Evidence-based Conclusions

Manipulative Therapy is defined as therapeutic manual application of pressure or force in which the practitioner moves or manipulates one or more parts of the body to diagnose, treat, and maintain patient health; examples include OMT/OMM, chiropractic treatments, manual therapy, physical therapy and massage. This policy explicitly references craniosacral therapy and other nonstandard techniques as variants but treats them separately in coverage determinations.

The policy excludes manipulation under anesthesia from this document and directs readers to the separate Medical Policy titled Manipulation Under Anesthesia (for New Jersey Only).

Evidence-based conclusions in this section

Findings summarized by condition:

ALL of the following

Carpal Tunnel Syndrome (CTS)
- CTS evidence: OMT resulted in participant-perceived improvement in symptoms and function associated with CTS, but no change in median nerve function/morphology; study limitations: unknown patient population and short follow-up.
Hip Osteoarthritis / Parkinson's disease gait

Definitions

Glossary (concise definitions):

Manipulative Therapy — therapeutic manual pressure or force in which the practitioner moves or manipulates one or more parts of the patient's body; includes OMT/OMM, manual therapy, chiropractic, physical therapy, and massage (definition per policy).

Musculoskeletal Disorders (MSDs) — injuries 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.

Upledger Technique / Craniosacral therapy (CST) — a light-touch, whole-body craniosacral approach developed by John E. Upledger; listed as an unproven/non-covered indication in this policy (note: a definition for Upledger Technique was added to the policy effective 07/01/2025).

OMT — Osteopathic manipulative treatment (hands-on care by osteopathic practitioners using manipulation, mobilization, and soft tissue techniques).

OMT-WB — Whole-body osteopathic manipulative treatment including OCMM.

OCMM — Osteopathic cranial manipulative medicine.

MC (Maintenance Care) — ongoing manipulative care intended for prevention or maintenance rather than restoration (considered unproven for many indications).

SMT — Spinal Manipulative Therapy: manual high-velocity low-amplitude thrusts or mobilization of the spine performed by various practitioners.

Nonstandard techniques (e.g., applied kinesiology, NUCCA, neural organizational technique) — techniques for which no published peer-reviewed literature was identified in the policy.

Coding (referenced procedure codes)

Referenced Procedure Codes (OMT / CMT / extraspinal / maintenance)CPT|HCPCS

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
97140	Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes (see Habilitation and Rehabilitation Therapy policy for details)

1–10 of 11

1/2

Clarification for billing: CPT/HCPCS codes 98926–98929 and 98943 are marked with an asterisk in the policy as not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by New Jersey Medicaid. Providers should verify coverage and reimbursement applicability per the State Fee Schedule and follow the policy's documentation and coding guidance when billing.

Provider Actions & Billing Guidance

Documentation Required

Indication documentation

Providers must document the musculoskeletal disorder (MSD) indication and demonstrate medical necessity for manipulative therapy. Documentation should clearly state the diagnosed condition, presenting symptoms, objective findings, and functional limitations attributable to the MSD. Include the clinical rationale showing the intervention is intended to restore or improve function (not for maintenance or custodial care). Documentation should be contemporaneous, legible, and maintained in the medical record for audit.

Condition-specific indication (e.g., acute/chronic low back pain, neck pain, radiculopathy) with diagnostic evidence
Symptoms, exam findings, and functional limitations (pain scores, range of motion, neurologic deficits, ADL impact)
Prior conservative care and response (e.g., medications, physical therapy, activity modification) including dates and outcomes
Treatment plan details: type of manipulative therapy, targeted body regions, frequency, and expected therapeutic goals
Progress notes and follow-up outcomes showing objective improvement or treatment effect and justification for continued care
Explicit statement when therapy is NOT maintenance or custodial—note specific restorative goals

Evidence & References Summary

The evidence dataset includes multiple systematic reviews, meta-analyses, and randomized controlled trials (examples cited through 2024–2025) covering a range of musculoskeletal and non-musculoskeletal conditions. While several high-volume syntheses report potential short-term benefits for select musculoskeletal conditions, important limitations recur across the literature.

Common limitations include substantial heterogeneity in interventions and outcomes, small or single-session trials, short follow-up durations, variable risk-of-bias ratings, and inconsistent reporting of harms — all of which constrain confidence in long-term effectiveness and generalizability.

Study / Source	Design / n	Key finding
Hoeksma et al. (2004) hip OA RCT	Randomized clinical trial; n=109 (manual therapy n=56 vs exercise n=53)	Manual therapy success rate 81% vs 50% at 5 weeks; superior improvements in pain, stiffness, function, ROM maintained at 29 weeks
Reza et al. (2021) knee OA RCT	Two-arm randomized trial; n=32 (exercise alone vs manual therapies + exercise)	Manual therapies + exercise superior to exercise alone on NPRS and WOMAC at 2 and 4 weeks; limited by small sample and short follow-up
Dunning et al. (2024) TMD RCT	Multi-center randomized clinical trial; n=120 (dry needling + upper cervical spinal manipulation n=62 vs splint + diclofenac + TMJ mobilization n=58)	Dry needling + upper cervical spinal manipulation produced greater reductions in jaw pain intensity and greater active pain-free mouth opening at 3 months (p<0.001); study limitations include no placebo and potential treatment bias
Kawchuk et al. (2020) rapid evidence review	Rapid review of cited literature (7 studies assessed); n not pooled	Concluded no credible scientific evidence that spinal manipulation confers or enhances immunity; studies small and lacked symptomatic subjects
Amendolara et al. (2024) CST meta-analysis	Systematic review & meta-analysis of RCTs; 24 RCTs, n=1,613	No significant effects for primary outcomes overall; some secondary/subgroup signals (neonate health, chronic pain) but wide prediction intervals, high bias, and low certainty — overall lack of usefulness

Revision History

07/01/2025added

Added definition of 'Upledger Technique' to Definitions section.

07/01/2025revised

Supporting information updated: Clinical Evidence and References sections updated and previous policy version CS076NJ.N archived.

09/01/2025removedLatest

Removed reference links to Diagnostic Spinal Ultrasonography (for New Jersey Only) and Neuropsychological Testing Under the Medical Benefit (for New Jersey Only) — retired Sep. 1, 2025.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for New Jersey Only)

Policy CodePolicy CS076NJ.O

Change TypeDefinitions added; references updated; link removed

Effective DateJuly 1, 2025

Next Review Date

SourceLink

On This Page

Prevention/Maintenance: Prevention, maintenance, or custodial care

Craniosacral Therapy: Craniosacral therapy (cranial manipulation/Upledger Technique)

Temporomandibular Joint: Temporomandibular joint (TMJ) disorder

Non-standard Techniques: Manipulative services that utilize nonstandard techniques (e.g., applied kinesiology including the neural organizational technique, National Upper Cervical Chiropractic Association (NUCCA) process)

Policy Scope / Applicability

This policy applies to:

Applicability: State of New Jersey only

PD gait trial: Single session OMT-WB increased total sagittal hip ROM in PD participants (p = 0.038); waveform analysis found no differences at individual gait cycle points; limitations: single session, no follow-up; larger longitudinal studies needed.
Hip OA reviews/trials: Systematic reviews indicate exercise more effective than minimal control for hip OA pain; low-quality evidence showed short-term benefit of manual therapy; need larger RCTs. Hoeksma et al. (2004) RCT: manual therapy superior to exercise therapy for hip OA at 5 weeks and maintained at 29 weeks (success rates 81% vs 50%).

Knee Osteoarthritis / Postoperative TKA

Post-TKA evidence: Systematic review suggests OMT may improve ROM, edema, pain, ADLs after TKA; studies heterogeneous and mostly nonrandomized; further research needed.
Reza 2021: Reza et al. (2021) RCT (n=32): manual therapies + exercise superior to exercise alone on NPRS and WOMAC at 2 and 4 weeks; limitations: small sample, short follow-up.
Altinbilek 2018: Altinbilek et al. (2018) RCT (n=100): exercise + OMT yielded greater functional improvement and pain relief vs exercise alone; short-term follow-up.
Salahm 2017: Systematic review/meta-analysis (Salahm et al. 2017) supports manual therapy for self-reported knee function; less support for pain reduction; conclusions limited by study quality.

Ankle and Foot

Plaza-Manzano 2016: Plaza-Manzano et al. (2016) RCT (n=56): proprioceptive exercises + manual therapy improved pain, functional instability, strength, ROM versus exercises alone; larger longer studies needed.
du Plessis 2011: du Plessis et al. (2011) RCT: manual/manipulative therapy equivalent to night splint for mild-moderate hallux abducto valgus in short term.
Cleland 2009: Cleland et al. (2009) multicenter RCT (n=60): manual physical therapy + exercise (MTEX) produced greater clinical benefits in function and pain than electrophysical agents + exercise (EPAX) for plantar heel pain.

Headache (cervicogenic, migraine, tension-type)

Headache syntheses: Systematic reviews/meta-analyses indicate spinal manipulation/mobilization may be effective for cervicogenic headache and may reduce migraine days and pain/intensity; quality variable and further large RCTs needed.
Comparative findings: Manipulation/mobilization found equally effective as other conservative treatments for cervicogenic headache; more effective short-term for tension-type headache; manual therapy may improve quality of life for tension-type and migraine headaches but evidence low and at risk of bias.

Temporomandibular Joint Disorders (TMD)

Overall TMD evidence: Evidence insufficient to consider manual therapy safe and effective for TMD; small RCTs and systematic reviews show mixed results and methodological limitations.
Al-Moraissi 2024: Al-Moraissi et al. (2024) network meta-analysis (n=202 across 3 RCTs): manual therapy showed greater TMJ pain reduction vs conservative therapy; limited by small sample sizes.
Dunning 2024: Dunning et al. (2024) multicenter RCT (n=120): dry needling + upper cervical spinal manipulation more effective than interocclusal splint, diclofenac, and TMJ mobilization at 3 months; limitations include lack of placebo and potential treatment bias.

Preventive (maintenance) manipulative treatment

Insufficient evidence for maintenance: Insufficient evidence to support manipulative therapy for prevention, maintenance, or custodial care; existing trials show mixed effects and subgroup-specific findings; further research needed.
Eklund trials: Eklund et al. (2019, 2018) pragmatic MC trials: maintenance care reduced days with bothersome LBP in certain psychological subgroups (DYS) but effects vary by subgroup; reductions may not reach prespecified clinically meaningful thresholds; MC increased number of treatments.
Senna 2011: Senna and Machaly (2011) RCT: maintenance manipulation showed lower pain/disability vs control, but study limited by high dropout and methodological flaws.

Non-musculoskeletal conditions (asthma, otitis media, infantile colic, depression, immune outcomes)

Insufficient/negative evidence: Long-term safety and effectiveness of manual therapies for non-musculoskeletal conditions not demonstrated; preliminary studies show biomarker changes or small clinical signals but clinical significance unknown.
Hope-Bell 2024: Hope-Bell et al. (2024) feasibility RCT (n=42): osteopathic interventions feasible and acceptable for mild psychological symptoms; exploratory changes in HRV and mental health measures but small sample and short follow-up.
Pala 2024: Pala et al. (2024) RCT (n=39): osteopathic sympathetic harmonization altered α-amylase and cortisol in depressed youth acutely; no between-group differences in anxiety scores; limitations include potential placebo touch effects.
Chow 2021: Chow et al. (2021) systematic review: SMT associated with immediate changes in some immunological biomarkers; duration and clinical significance unknown; evidence neither supports nor refutes efficacy for immune/infectious outcomes.

Evidence-based conclusions (narrative criteria)

Coverage conclusions based on reviewed evidence in this section:

ALL of the following

Immunity/Immune Effects: Spinal manipulation and other manipulative therapies show no credible evidence for conferring or enhancing immunity; use to treat or prevent infectious disease is unproven.
Based on rapid evidence review (Kawchuk et al., 2020)
Visceral/Internal Organ Disorders: Evidence is limited/insufficient to conclude manipulative therapy is effective for visceral/internal organ disorders; additional high-quality studies needed.
Narrative conclusions from multiple RCTs and reviews
Therapy-specific conclusions
- OMT: Osteopathic manipulative treatment (OMT): some RCTs and systematic reviews show potential short-term or condition-specific benefit (e.g., infantile colic, preterm infant length of stay), but overall evidence is conflicting, low quality, or insufficient for generalization.
  Multiple systematic reviews cited (Buffone 2022; Franke 2022; Parnell Prevost 2019)
- Craniosacral Therapy (CST): Craniosacral therapy (CST): systematic reviews and meta-analyses generally find no reliable clinically significant effects across musculoskeletal or non-musculoskeletal conditions; evidence quality poor and inconsistent.
  Multiple reviews and RCTs (Amendolara 2024; Ceballos-Laita 2024; Cook 2024; Haller et al.)
- Visceral Manipulation/OVM: Visceral manipulation/osteopathic visceral manipulation: some RCTs report statistically significant results for outcomes like GERD symptoms or constipation/low back pain combinations, but clinical relevance, small samples, short follow-up, and methodological limitations prevent firm conclusions.
  Boas Fernandes 2023; Eguaras 2019; Panagopoulos 2015
- Non-standard Techniques: Non-standard techniques (applied kinesiology, NUCCA, NOT): no published peer-reviewed literature identified.
  Policy statement
Pediatric Non-MSK: For pediatric non-musculoskeletal conditions (infantile colic, asthma, otitis media, etc.), high-quality trials generally do not show benefit of SMT/OMT; systematic reviews indicate lack of evidence to support effectiveness.
Global Summit (Côté et al. 2021); Franke 2022
Guideline Variability: Guideline positions vary: ACP/APS recommend spinal manipulation as one of several nonpharmacologic options for low back pain; AOA considers evidence for OMT weak and calls for larger RCTs; IFOMPT/IOPTP restricts manipulation in infants/children for non-musculoskeletal pediatric conditions.
Guideline summaries included

The evidence section summarizes multiple systematic reviews, randomized controlled trials, and meta-analyses up to 2025. While many RCTs and SRs report condition-specific or short-term benefits (particularly for musculoskeletal conditions), study quality is variable.

Overall evidence quality is heterogeneous and often limited by small sample sizes, short follow-up, methodological limitations, and risk of bias; evidence is generally insufficient to support use of manipulative therapies for many non-musculoskeletal indications.

Billing Rule

State Fee Schedule exclusion note

Certain OMT/CMT codes are not listed on the New Jersey Medicaid Fee Schedule and may not be payable. Before submitting claims, providers should verify plan-specific coverage and reimbursement for these codes with UnitedHealthcare and the State fee schedule.

Affected codes not on NJ Medicaid Fee Schedule: 98926, 98927, 98928, 98929, 98943
Codes on the Fee Schedule may still require documentation of medical necessity and proper linkage to the MSD diagnosis

Documentation Required

Coding Clarification

Refer to the separate Medical Policy titled Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Jersey Only) for guidance on interplay with CPT 97140 (manual therapy techniques). When services could be reported under 97140, ensure documentation supports code selection and avoid duplicate billing for identical manual therapy maneuvers.

See Habilitation and Rehabilitation Therapy (for New Jersey Only) for rules regarding CPT 97140 vs OMT/CMT codes
Document distinct service components, time, and clinical purpose when reporting 97140 alongside manipulative therapy codes

Prior Authorization

Prior authorization rationale (policy context)

Prior authorization may be required or recommended for manipulative therapy when used for non-musculoskeletal or pediatric indications due to limited or mixed evidence supporting efficacy. Use prior authorization to review medical necessity, particularly for indications deemed unproven by this policy.

Non‑musculoskeletal indications (e.g., asthma, otitis media, infantile colic) and many pediatric uses have limited evidence and may require review
Prior authorization supports validation that treatment is restorative and medically necessary rather than maintenance/custodial

Documentation Required

Use policy with plan-specific requirements

This policy is subject to federal, state, and contractual requirements that govern benefits and coverage. UnitedHealthcare may apply plan-specific rules, third-party tools, or utilization management processes that supersede or refine this policy. Providers must follow applicable regulatory and contractual requirements and confirm any plan-specific instructions.

Federal/state/contractual rules take precedence over this policy
UnitedHealthcare may use third‑party tools or program edits that affect coverage, prior authorization, and payment