CurrentUnitedHealthcarePolicy 496

Medicare Chiropractic Services – Clinical Guideline

Defines Medicare-based clinical criteria, documentation requirements, and use of InterQual® Outpatient Rehabilitation & Chiropractic criteria for coverage of chiropractic manipulative treatment (CMT) limited to manual manipulation of the spine to correct a subluxation. Also describes review process for initial and ongoing care and lists related CPT codes for CMT.

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Chiropractic Services – Clinical Guideline

Policy CodePolicy 496

Change TypeRevisions; interim documentation update

Effective DateFeb 11, 2026

Next Review Date

Key ActionProviders must document demonstration of subluxation by x-ray or by meeting two of four specified physical exam criteria (one must be asymmetry/misalignment or ROM abnormality).

SourceLink

POLICY UPDATE CHANGES

Added discussion concerning benefits vs. harms of InterQual® criteria and inserted link to InterQual® criteria (04/09/2024).

Interim revision to documentation requirements supporting medical necessity of requests for chiropractic care beyond the initial course of treatment (08/13/2025).

Annual reviews on 02/10/2026 and 02/11/2026 with no substantive changes.

3CMT CPT codes listed

1Required primary diagnosis

2Min physical exam criteria (if used)

Coverage Summary

Overview: Medicare-based coverage with criteria. This policy (Effective: 02/11/2026; Last review: 02/11/2026; Status: CURRENT) defines Medicare-based clinical criteria and documentation requirements for chiropractic manipulative treatment (CMT) limited to manual manipulation of the spine to correct a subluxation. The policy aligns with CMS Medicare Benefit Policy Manual Chapter 15 and supplements Medicare criteria by using InterQual® Outpatient Rehabilitation & Chiropractic Criteria to guide appropriateness and consistency of approvals.

Key Stats

CMT CPT codes listed98940; 98941; 98942

Required primary diagnosis (subluxation)Primary diagnosis must be subluxation of the spine (level specified), demonstrated by x-ray or physical exam

Physical exam criteria required - minimumWhen demonstration is by physical exam, at least 2 of 4 criteria required, and one must be asymmetry/misalignment or range of motion abnormality

Medical Necessity Criteria

Medically Necessary Chiropractic Care (General Policy Statement)

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

ALL of the following

Patient has a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered have a direct therapeutic relationship to the patient's condition with reasonable expectation of recovery or improvement of function (per Medicare Benefit Policy Manual Chapter 15, Section 240.1.3).
Individual has a primary diagnosis of subluxation of the spine as demonstrated by x-ray or physical examination.
The precise level of the subluxation is specified by the chiropractor.
Manual manipulation of one or more spinal regions is planned.

Initial Course of Treatment Requirements

Coding

Chiropractic Manipulative Treatment (CMT) CPT codes (reference list)CPT

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

Provider Actions & Requirements

Documentation Required

Document demonstration of subluxation

Providers must document demonstration of subluxation by x-ray or by meeting two of four specified physical exam criteria (one must be asymmetry/misalignment or ROM abnormality). Note: if demonstration is by physical exam, two of the four criteria are required and one of those two MUST be either asymmetry/misalignment or range of motion abnormality.

Pain/tenderness evaluated in terms of location, quality, and intensity
Asymmetry/misalignment identified on a sectional or segmental level
Range of motion abnormality
Tissue/tone changes in contiguous or associated soft tissues (skin, fascia, muscle, ligament)

Documentation Required

Submit detailed initial treatment documentation

Background & Definitions

Background: This policy aligns with CMS Publication 100-02, Medicare Benefit Policy Manual Chapter 15, which limits Medicare coverage for chiropractic care to treatment by means of manual manipulation of the spine to correct a subluxation. Optum supplements those Medicare criteria with InterQual® Outpatient Rehabilitation & Chiropractic Criteria to help determine when outpatient rehabilitation and chiropractic services are reasonable and necessary, provide consistency in approval from a dosage and appropriateness standpoint, and incorporate current evidence-based guidance.

Subluxation: A motion segment in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact; may be demonstrated on x-ray or physical examination.

Manual manipulation (CMT): Chiropractic manipulative treatment to influence joint and neurophysiological function using various techniques, with expected result of improvement in or arrest of progression of the patient's condition.

Medicare Determinations

Medicare determinations: Per Medicare Benefit Policy Manual Chapter 15: Chiropractic Services, Medicare coverage for chiropractic care is limited to manual manipulation of the spine to correct a subluxation; all other services furnished or ordered by chiropractors are not covered. The policy refers clinicians to the Medicare Coverage Database and Medicare Benefit Policy Manual Chapter 15 as the primary sources for medical necessity determinations for chiropractic services.

Revision History

04/09/2024revised

Added discussion concerning benefits vs. harms of InterQual® criteria and inserted link to InterQual® criteria. InterQual® criteria are used to supplement Medicare criteria for outpatient rehabilitation & chiropractic appropriateness; benefits and potential harms described.

08/13/2025revised (material)

Interim revision to documentation requirements supporting medical necessity of requests for chiropractic care beyond the initial course of treatment; updated/clarified expectations for ongoing care documentation.

02/10/2026revised

Annual review approved by Optum Clinical Guideline Advisory Committee with no substantive changes.

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Chiropractic Services – Clinical Guideline

Policy CodePolicy 496

Change TypeRevisions; interim documentation update

Effective DateFeb 11, 2026

Next Review Date

Key ActionProviders must document demonstration of subluxation by x-ray or by meeting two of four specified physical exam criteria (one must be asymmetry/misalignment or ROM abnormality).

SourceLink

On This Page

Covered when ALL of the following are met:

ALL of the following

A subluxation must be demonstrated on x-ray or physical examination.
If demonstration is by physical examination, TWO of the FOUR specific criteria are required, one of which must be asymmetry/misalignment or range of motion abnormality
- Pain/tenderness evaluated in terms of location, quality, and intensity
- Asymmetry/misalignment identified on a sectional or segmental level
- Range of motion abnormality
- Tissue/tone changes in contiguous or associated soft tissues including skin, fascia, muscle, and ligament
Relevant personal and family health history provided.
Description of present illness including symptoms that bear a direct relationship to the level of subluxation, quality and character of symptoms/problem, mechanism of trauma, onset, duration, intensity, frequency, location and radiation of symptoms, aggravating or relieving factors, prior interventions/treatments/medications, and secondary complaints.
Evaluation of the musculoskeletal/nervous system through physical examination.
Primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation (condition of the spinal joint involved or direction/position of the bone).
Treatment plan including recommended level of care, duration and frequency of visits, specific treatment goals, objective measures to evaluate treatment effectiveness, and date of initial treatment.

Care Beyond Initial Course of Treatment (Ongoing Care)

For additional treatment beyond the initial course, ALL of the following documentation must be provided to justify medical necessity and reasonableness:

ALL of the following

History: review of chief complaint and changes since last visit (including system review if relevant).
Physical examination: examination of the area of the spine involved in the diagnosis, assessment of change in patient condition since last visit, and evaluation of treatment effectiveness.
Documentation of treatment given on day of visit.
Documentation of treatment frequency, duration, and anticipated length of treatment session(s).
All ongoing care is reviewed by an Optum clinical specialist provider and is subject to benefit restrictions, state/federal mandates/regulations, and documentation of medical necessity and reasonableness.

Not Medically Necessary / Exclusions

The following are NOT considered medically necessary under this policy:

ANY of the following

Chiropractic maintenance therapy when further clinical improvement cannot reasonably be expected and treatment is supportive rather than corrective (maintenance therapy is not reasonable or necessary).
Chiropractic manipulation for non-neuromusculoskeletal conditions.
All services furnished or ordered by chiropractors other than manual manipulation of the spine to correct a subluxation (per CMS Pub 100-02, Chapter 15, Section 30.5).

Initial course requests must include relevant personal and family history, a detailed description of the present illness, musculoskeletal and nervous system examination findings, primary diagnosis specifying the level of subluxation, and a treatment plan that includes recommended level of care, duration and frequency of visits, specific treatment goals, objective measures to evaluate effectiveness, and date of initial treatment.

Relevant personal and family health history
Description of 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, secondary complaints)
Evaluation of the musculoskeletal/nervous system through physical examination
Primary diagnosis = subluxation with specified level
Treatment plan: level of care, duration/frequency, specific goals, objective outcome measures, date of initial treatment

Documentation Required

Provide documentation for ongoing care

Requests for care beyond the initial course must document review of the chief complaint and changes since the last visit, spinal examination focused on the diagnosed area with assessment of change and evaluation of treatment effectiveness, documentation of treatment provided on the day of visit, and the treatment frequency, duration, and anticipated length of sessions to justify ongoing medical necessity.

History: review of chief complaint and changes since last visit (include system review if relevant)
Physical exam: examination of the spinal area involved, assessment of change since last visit, evaluation of treatment effectiveness
Documentation of treatment given on the day of visit
Documentation of treatment frequency, duration, and anticipated length of treatment sessions

Prior Authorization

Ongoing care review by Optum clinical specialist

All ongoing care is reviewed by an Optum clinical specialist provider. Determinations regarding ongoing care are subject to applicable benefit restrictions, state and federal mandates/regulations, and require documentation of medical necessity and reasonableness.

Denial Risk

Risk of denial for insufficient documentation or non-applicable diagnosis

Claims may be denied if documentation does not demonstrate subluxation per criteria, if treatment is maintenance rather than corrective, or if manipulation is provided for non-neuromusculoskeletal conditions.

Failure to demonstrate subluxation by x-ray or required physical exam criteria
Treatment that is maintenance/supportive with no reasonable expectation of further clinical improvement
Manipulation provided for non-neuromusculoskeletal conditions

02/11/2026revisedLatest

Annual review approved by Medicare Advantage Policy and Technology Assessment Committee (MAP-TAC) with no substantive changes.