CurrentUnitedHealthcarePolicy CSO76TN.R

Manipulative Therapy (for Tennessee Only)

This policy governs coverage and clinical indications for manipulative therapies (including osteopathic and chiropractic manipulative treatment) for Tennessee Medicaid and CoverKids members (excluding CoverKids for pregnant women 19+). It defines covered indications, unproven uses, applicable codes, and references to InterQual criteria.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Tennessee Only)

Policy CodePolicy CSO76TN.R

Change TypeDefinitions and supporting references updatedrelated policies removed

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization per InterQual Outpatient Rehabilitation & Chiropractic criteria when requesting chiropractic manipulative therapy.

SourceLink

POLICY UPDATE CHANGES

Related Policies Removed reference link to the Medical Policy titled: Diagnostic Spinal Ultrasonography (for Tennessee Only)

Definitions Added definition of "Upledger Technique"

Supporting Information Updated Clinical Evidence and References sections to reflect the most current information

Archived previous policy version CSOZ6TN.Q

TennesseeGeographic application

98925-98929, 98940-98943, S8990Procedure/HCPCS codes listed

Systematic reviews & RCTs (2013-2024)Evidence base

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Common study limitation

9Conditions summarized

Coverage Criteria and Evidence Summary

Medically Necessary Indications

Covered when ALL of the following are met:

Medical necessity for MSDs: Manipulative Therapy (including OMT/OMM and chiropractic CMT) is proven and medically necessary for treating Musculoskeletal Disorders when documentation meets InterQual Outpatient Rehabilitation & Chiropractic medical necessity criteria.InterQual criteria

Refer to InterQual LOC: Outpatient Rehabilitation & Chiropractic for specific clinical criteria and documentation requirements.

Unproven / Not Medically Necessary Indications

Not medically necessary / Unproven:

Unproven indications: Manipulative Therapy and specific techniques (including craniosacral therapy/cranial manipulation/Upledger Technique, nonstandard techniques such as applied kinesiology or NUCCA, prevention/maintenance/custodial care, non‑musculoskeletal disorders such as asthma, otitis media, infantile colic, internal organ disorders, scoliosis, and temporomandibular joint (TMJ) disorder) are considered unproven and not medically necessary due to insufficient evidence of efficacy.

Policy lists examples but is not necessarily limited to them.

Summaries by condition

Summarized clinical evidence and primary findings by condition from cited studies

Scoliosis evidence: Multiple small studies, case series, cohorts and limited RCT data report possible short‑term curve stabilization or modest Cobb angle changes with various manual or combined interventions, but small sample sizes, retrospective designs, lack of controls, measurement bias, and heterogeneity preclude definitive effectiveness conclusions.

See small case series and systematic reviews noting insufficient evidence.

Neck pain evidence: Systematic reviews and RCTs report manipulative therapy may reduce chronic neck pain and disability versus exercise or control in the short term, though heterogeneity and low/very low quality of evidence limit the strength of recommendations.

Includes Groisman et al. RCT and Liu et al. 2023 systematic review.

Shoulder disorders: Trials and reviews indicate manual therapy combined with exercise can improve pain, function and range of motion in shoulder conditions compared with exercise alone or control, but study quality and follow‑up duration limit certainty about long‑term effects.

Includes Spencer MET and other RCTs/systematic reviews.

Condition-specific evidence summaries

Summarized findings relevant to coverage decisions:

Plantar heel pain: A multicenter RCT (Cleland et al., n=60) found both electrophysical agents plus exercise and manual physical therapy plus exercise improved outcomes over six months; manual therapy plus exercise produced greater functional benefit in that trial.

Small trial supports adding manual therapy to exercise for plantar heel pain.

Headache (cervicogenic, migraine, tension-type): Evidence syntheses report short‑term reductions in migraine days and pain intensity with spinal manipulation and favorable effects for cervicogenic headache and tension‑type headache in some trials; overall evidence quality and risk of bias vary across studies.

Meta‑analyses show preliminary benefit but call for larger, rigorous RCTs.

Temporomandibular disorders (TMD): Multiple small RCTs and systematic reviews report mixed results; some analyses show reduced TMJ pain and increased maximal mouth opening with manual therapy compared to conservative care, but small sample sizes and heterogeneity limit definitive coverage conclusions.

Additional high‑quality trials needed before definitive policy change.

Evidence-based coverage summary

Summary evidence‑based stance

General evidence-based coverage stance: Craniosacral therapy (CST), spinal manipulative therapy (SMT) for non‑musculoskeletal disorders, and visceral manipulation lack consistent, high‑quality evidence of clinical benefit; single small trials with positive findings are insufficient for routine coverage.

Multiple systematic reviews and meta‑analyses conclude insufficient evidence; limitations include small sample sizes, heterogeneity, bias, and short follow‑up.

Preliminary/limited evidence signals

Conditions with limited or preliminary positive signals (not definitive coverage criteria)

Preliminary positive signals: Some meta‑analyses and small RCTs observed short‑term physiologic or symptom changes (e.g., HRV parasympathetic increase after CST; small RCTs reporting reduced crying in infantile colic or reduced migraine frequency/intensity with CST), but wide prediction intervals, high risk of bias and small sample sizes mean these signals are hypothesis‑generating only and do not establish effectiveness for coverage purposes.

Findings require replication in larger, well‑designed trials before informing coverage.

General effectiveness assessment

Evidence-summary based stance

Overall evidence summary: Systematic reviews and RCTs of craniosacral therapy are generally small, heterogeneous, and at risk of bias; well‑conducted trials are few and results are modest or inconsistent, and diagnostic reliability for cranial osteopathy/CST is not supported.

Authors of reviews recommend caution and further high‑quality research.

Physiologic outcomes

Physiologic evidence (short-term)

HRV meta-analysis result: A meta‑analysis (Cook et al. 2024) of three primary studies found a moderate short‑term increase in parasympathetic activity after CST (HF standardized mean difference = -0.46; 95% CI -0.79 to -0.14) and no significant effect on LF power.

Authors cautioned about small study numbers, heterogeneity, and potential placebo effects.

Clinical trial summaries

Condition-specific trial findings (limited/small trials)

Infantile colic RCTs: Small RCTs (e.g., Castejon‑Castejon 2019/2022; n=58) reported reductions in crying hours and improved sleep after 2–3 CST sessions versus no treatment, but studies were small, unblinded and at high risk of bias and are not generalizable.

Evidence insufficient to support routine coverage for infantile colic.

Migraine RCT: Munoz‑Gomez et al. (2022) RCT (n=50) reported reductions in pain, episode frequency, disability and medication intake with CST versus sham, maintained at eight weeks; however, small sample size and methodological limitations require validation before changing coverage stance.

Single small positive RCT—requires replication.

Cohort and preliminary studies: Prospective cohort data (Haller 2021) and preliminary reports report symptom and disability improvements with CST, but observational designs, therapist/patient selection and expectation effects limit causal inference; randomized validation is needed.

Considered exploratory evidence only.

Manipulative Therapy (including osteopathic and chiropractic manipulative techniques) is unproven and not medically necessary when used for prevention, maintenance, or custodial care. The policy explicitly lists these uses among other non‑evidence‑based indications and indicates such services may be denied when billed for these purposes.

Across multiple systematic reviews and small trials, reviewers consistently note lack of high‑quality data, heterogeneity of techniques and outcomes, and substantial risk of bias. Because of these limitations, claims that manipulative or manual therapies produce durable, long‑term structural changes (for example definitive Cobb angle correction in scoliosis) are not supported.

Manual therapies have not demonstrated reliable long‑term safety or effectiveness for non‑neuromusculoskeletal conditions (examples include hypertension, asthma, otitis media, and infantile colic). The literature to date is small, short‑term, and methodologically limited; therefore these indications are not supported for routine coverage.

Systematic reviews of spinal manipulative therapy (SMT) for non‑musculoskeletal disorders report that the highest‑quality randomized trials show no benefit of SMT versus sham or control interventions for conditions such as infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine.

Clinical guideline organizations (IFOMPT/IOPTP) advise that spinal manipulation and mobilization are not recommended for infants and should be avoided for non‑musculoskeletal pediatric conditions (for example infantile colic, asthma, breastfeeding difficulties, cerebral palsy, otitis media, ADHD/autism spectrum disorder). These pediatric recommendations restrict manipulative therapy outside appropriately indicated musculoskeletal uses.

Related policy references specific to Tennessee that previously appeared in this document have been removed or retired; the policy history notes those links were removed on the Sep. 1, 2025 revision and the prior policy version was archived.

Use of manipulative therapy for the listed unproven indications — including but not limited to scoliosis, craniosacral therapy, TMJ disorder, non‑musculoskeletal disorders, nonstandard techniques, and preventive/maintenance care — is considered not medically necessary and may be denied absent compelling, condition‑specific evidence.

Many positive reports rely on low‑quality designs (case series, small retrospective reviews) with measurement limitations and absent controls. Such evidence should not be used to justify long‑term replacement or corrective therapies (for example claiming definitive scoliosis curve correction) without rigorous corroborating trials.

Preventive or custodial application of manipulative therapies lacks sufficient evidence to establish effectiveness; therefore use for routine prevention or maintenance is not covered and considered not medically necessary.

Craniosacral therapy (CST) and spinal manipulative therapy (SMT) when proposed for non‑musculoskeletal disorders are not supported by consistent, high‑quality evidence. Multiple systematic reviews and meta‑analyses find insufficient or negative results for CST/SMT in these indications, and routine coverage is not justified.

Critical evidence syntheses (Guillaud et al. 2016 and subsequent assessments) conclude there is insufficient evidence to support CST for diagnosis or treatment. These reviews note diagnostic unreliability and study bias, supporting the characterization of CST as an unproven therapy.

Applicable Procedure and HCPCS Codes

Applicable Procedure/HCPCS CodesCPT|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 involved regions.
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.
S8990	Physical or manipulative therapy performed for maintenance rather than restoration.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Coverage for manipulative therapy for musculoskeletal disorders is subject to meeting InterQual® Outpatient Rehabilitation & Chiropractic criteria. Verify plan-specific requirements and obtain prior authorization when the member's benefit plan or state/federal contract requires it.

Check InterQual outpatient rehabilitation & chiropractic criteria for medical necessity determination.
Confirm whether the member’s benefit plan or applicable federal/state contractual requirements impose prior authorization before scheduling services.
When prior authorization is required, document how the patient meets InterQual criteria in the request (see documentation bullets).

Documentation Required

Therapy and Co-intervention Documentation

Document the specific manual therapy technique, targeted body regions, frequency, duration, and all co-interventions (for example: supervised exercise, education, or home-exercise programs). For interventions combined with exercise, record whether exercise was the primary treatment and the supervised/unsupervised status of exercise.

Background and Context

Manipulative Therapy encompasses osteopathic, chiropractic, and other manual techniques used to assess and treat musculoskeletal complaints by manual mobilization or manipulation of joints and soft tissues. When applied to musculoskeletal disorders with documentation meeting InterQual Outpatient Rehabilitation & Chiropractic criteria, manipulative therapy may be medically necessary; however, many other uses described in the literature fall outside evidence‑based indications.

Definitions

Manipulative Therapy — definition key value

TermManipulative Therapy

DefinitionTherapeutic application of manual pressure or force in which the practitioner moves or manipulates one or more parts of the patient’s body to evaluate and treat structural and functional issues in bones, joints, tissues, and muscles; includes OMT/OMM, chiropractic, physical therapy mobilization/manipulation, and related manual techniques.

ExamplesOsteopathic manipulative treatment (OMT), chiropractic manipulative treatment (CMT), manual therapy, body‑based practices, and massage techniques.

Musculoskeletal Disorders — definition key value

TermMusculoskeletal Disorders (MSDs)

DefinitionInjuries or conditions originating from joints, muscles, ligaments, discs, or other soft tissues in the spine or limbs that produce clinically relevant signs or symptoms.

Policy Change Log

09/01/2025related_policies_removedLatest

Removed references to retired related policies (Diagnostic Spinal Ultrasonography and Neuropsychological Testing) from the policy.

07/01/2025definition_added

Added a definition for the 'Upledger Technique' to the policy's definitions section.

07/01/2025references_updated

Updated the Clinical Evidence and References sections to reflect current literature and supporting information.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Tennessee Only)

Policy CodePolicy CSO76TN.R

Change TypeDefinitions and supporting references updatedrelated policies removed

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization per InterQual Outpatient Rehabilitation & Chiropractic criteria when requesting chiropractic manipulative therapy.

SourceLink

On This Page

Elbow/wrist/hand: Systematic reviews show mobilization/manipulation may improve short‑ and intermediate‑term outcomes for lateral epicondyle disorders; limited evidence suggests patient‑perceived improvement for carpal tunnel symptoms without consistent nerve conduction changes.

Evidence base limited and variable quality.

Hip OA and Parkinsonian gait: Some RCTs report short‑term increases in hip range of motion and perceived benefit with OMT/OCMM in hip OA and Parkinson's disease gait measures, but single‑session findings and short follow‑up limit clinical relevance without longitudinal data.

See Terrell et al., Hoeksma and related systematic reviews.

Knee osteoarthritis: Randomized trials and systematic reviews suggest OMT or manual therapy added to exercise may yield greater short‑term pain and functional improvement than exercise alone; studies are generally small with short follow‑up.

Includes Reza et al., Altinbilek et al., and meta‑analyses.

Ankle and foot: Randomized trials show that adding manual therapy to exercise improves short‑term pain, stability, strength and range of motion for recurrent ankle sprain and plantar heel pain compared with exercise or electrophysical agents alone.

Includes Plaza‑Manzano, du Plessis, and Cleland multicenter RCT.

Headache (cervicogenic/migraine/tension): Systematic reviews and meta‑analyses indicate spinal manipulation, mobilization and other manual therapies can reduce pain intensity, frequency and disability in cervicogenic and some migraine/tension‑type headache trials in the short term; methodological heterogeneity and variable risk of bias temper confidence in long‑term benefit.

Includes Nunez‑Cabaleiro, Rist et al., Coelho et al., and Maistrello et al. syntheses.

Maintenance / Preventive Manipulative Treatment: Pragmatic RCT evidence (Eklund et al.) indicates maintenance chiropractic care may reduce days with bothersome low back pain for selected subgroups who respond to initial treatment, but overall effects did not meet predefined clinically meaningful thresholds for the entire study population; consider authorization only for documented responders.

Subgroup‑dependent benefit; document initial favorable response when considering maintenance care.

Non‑musculoskeletal disorders: High‑quality RCTs and systematic reviews show no consistent benefit of spinal manipulative therapy or related manual therapies for non‑musculoskeletal conditions (e.g., asthma, otitis media, infantile colic, hypertension); evidence does not support routine coverage for these indications.

See Global Summit and other systematic reviews reporting lack of effect for SMT in non‑MSD indications.

Specify modality (e.g., spinal manipulation, mobilization, osteopathic/manipulative treatment, craniosacral therapy) and CPT/HCP S codes used.
List co-interventions (exercise, myofascial techniques, visceral manipulation, education) and session-level details (minutes, repetitions, home program).
If manual therapy is added to a baseline exercise program, state rationale and prior conservative care tried.

Prior Authorization

Authorization Note for Maintenance Care

For maintenance (preventive) chiropractic care, authorization decisions should reflect limited evidence of clinical benefit and be reserved for selected responders who demonstrated clinically meaningful improvement with a documented trial of restorative care.

Document initial course response (objective and patient-reported) before approving maintenance care.
Include psychological/behavioral subgroup assessment (e.g., West Haven–Yale MPI) when available, as some subgroups derived differential benefit.
Consider time-limited authorizations and periodic re-evaluation of need and outcomes.

Prior Authorization

Prior Authorization Likely for CST/Visceral Manipulation

Prior authorization is likely required for craniosacral therapy (CST) and visceral/osteopathic visceral manipulation when used outside of musculoskeletal indications or when proposed as replacement therapy, given lack of high-quality evidence supporting efficacy.

When CST or visceral manipulation is requested, include justification, prior conservative care, and measurable outcome goals.
If proposed as replacement for guideline-recommended care, supply rationale and peer-reviewed evidence supporting the replacement.
Expect denials for non-musculoskeletal indications (e.g., asthma, colic, otitis media) without robust evidence.

Denial Risk

Denial Triggers for Non‑MSD or Unproven Techniques

Manipulative therapies for non-musculoskeletal disorders (prevention, maintenance, custodial care, or organ-system conditions) are not supported by sufficient evidence and are at high risk of denial. Providers should not submit claims as medically necessary for these indications unless contractually required.

Do not request coverage for SMT/CMT/OMT for non‑MSD indications (examples: asthma, otitis media, infantile colic, hypertension) without high-quality supporting evidence.
Services coded for maintenance rather than restoration (e.g., HCPCS S8990) are subject to heightened review and are commonly non-covered.
For pediatric, infant, or other vulnerable populations, include condition-specific evidence when requesting coverage; absence of evidence increases denial risk.

Documentation Required

Documentation Expectations for CST and Low‑Quality Evidence Techniques

When craniosacral therapy (CST) or other therapies with low-quality or heterogeneous evidence are used, document technique details, outcome measures, and informed consent acknowledging limited evidence.

Record treatment protocol (session length, number of sessions, practitioner training/experience).
Capture baseline and follow-up patient-reported outcomes (pain NRS, disability index such as ODI/WOMAC, MYMOP) and objective measures where applicable.
Include note of informed consent discussion regarding limited/uncertain evidence and alternative standard treatments.

Step Therapy

Exercise-First and Stepwise Use of Manual Therapy

Exercise-based care should be documented as first-line; manual therapy is commonly added as an adjunct or after a trial of exercise. Authorization requests should show prior or concurrent exercise interventions where indicated.

For shoulder, knee, and other extremity conditions, document supervised exercise trials (type, frequency, duration) before or alongside manual therapy.
Specify if manual therapy is intended to augment exercise (and how) or to be used after failure of exercise-only approaches.
Include objective functional outcomes and duration of conservative management attempted.

Note

Verify Prior Authorization with Benefit Plan

Verify benefit plan, federal/state, and contractual terms before applying this policy. UnitedHealthcare may use third‑party criteria (e.g., InterQual) to process authorization and coverage determinations; contractual requirements prevail in the event of conflict.

Reference the member’s specific benefit plan, state/federal mandates, and any carve‑outs that may affect coverage.
Note when InterQual or another third‑party tool was used in the decision and retain the decision record in the authorization file.
If plan language conflicts with this policy, follow the federal/state/contractual requirement governing the member's coverage.

ScopeIncludes spine and extremity disorders addressed by manipulative therapies (e.g., low back pain, neck pain, extremity joint disorders).

Craniosacral Therapy (CST) — definition (unproven)

TermCraniosacral Therapy (CST)

DefinitionA noninvasive osteopathic manual technique using light touch to detect and influence cranial and sacral rhythms and cerebrospinal fluid pulsations, with the goal of releasing restrictions without forceful manipulation.

Policy stanceConsidered unproven due to insufficient high‑quality evidence; routine coverage not supported for most indications.

Spinal manipulative therapy / manual therapy — definition key value

TermSpinal manipulative therapy / manual therapy

DefinitionTherapies including chiropractic, osteopathic, or physical therapy manipulations or mobilizations directed at the spine or extremity joints involving manual movement or mobilization techniques to restore function and reduce pain.

Use in trialsDescribed in randomized trials and systematic reviews evaluating effects on pain, function, range of motion, and structural outcomes (e.g., scoliosis studies).

Cobb angle — radiographic measurement referenced in AIS studies

TermCobb angle

DefinitionRadiographic measurement used to quantify the magnitude of spinal curvature (scoliosis); primary structural outcome in adolescent idiopathic scoliosis (AIS) studies.

ContextReported as change or progression/stabilization in AIS RCTs and cohort studies; interpretation limited by small samples and methodological issues in available studies.

Cervicogenic headache (CH) — definition key value

TermCervicogenic headache (CH)

DefinitionA headache originating from cervical spine structures; clinical trials evaluated spinal manipulation, mobilization, and other manual techniques for CH with short‑term improvements reported in some studies.

Evidence noteSystematic reviews report short‑term benefit of manual therapy for CH but methodological limitations reduce generalizability.

Temporomandibular disorder (TMD) — definition key value

TermTemporomandibular disorder (TMD)

DefinitionDisorders of the temporomandibular joint and associated structures; outcomes commonly reported include pain intensity, maximal mouth opening (MMO), and pressure pain thresholds (PPTs).

Evidence noteMeta-analyses and RCTs show mixed results with small sample sizes; additional high‑quality long‑term trials are needed before definitive coverage conclusions.

Craniosacral Therapy (CST) — definition reiteration (unproven)

TermCraniosacral therapy (CST)

ReiterationManual technique using gentle touch to influence cranial and sacral rhythms and cerebrospinal fluid flow; exploratory studies report symptom and physiologic changes but overall evidence quality is low.

Policy implicationGiven limited, heterogeneous, and at‑risk‑of‑bias trials, CST is considered unproven and not medically necessary for most indications absent robust condition‑specific evidence.

Osteopathic visceral manipulation (OVM) — definition key value

TermOsteopathic visceral manipulation (OVM)

DefinitionManual techniques that target visceral organs (e.g., stomach, liver, intestines) intended to affect visceral function and related somatic symptoms.

Evidence noteAvailable randomized trials are limited and inconsistent; evidence is insufficient to establish routine effectiveness for visceral disorders.

Heart rate variability (HRV) — physiologic measure definition

TermHeart rate variability (HRV)

DefinitionPhysiologic measure of autonomic nervous system activity analyzed in high‑frequency (HF) and low‑frequency (LF) bands, with HF reflecting parasympathetic activity and LF reflecting sympathetic/combined influences.

Context in CST researchMeta-analysis of CST studies reported a moderate short‑term increase in parasympathetic activity (HF standardized mean difference = -0.46; 95% CI -0.79 to -0.14) with no significant effect on LF.

MYMOP (adapted NRS) — patient-reported outcome definition

TermMYMOP (adapted NRS)

DefinitionMeasure Yourself Medical Outcome Profile adapted to an 11‑point numerical rating scale (NRS) used to assess symptom intensity, functional disability, and quality of life in CST cohort studies.

Use in studiesProspective CST cohort used adapted MYMOP to report pre/post changes in symptom intensity, disability, and quality of life across patient records.

Upledger Technique — definition added to policy definitions section

TermUpledger Technique

DefinitionA complementary light‑touch, whole‑body treatment developed by John E. Upledger that works with the craniosacral system to support the central nervous system and improve stress coping and self‑care capacity.

Policy noteDefinition was added to the policy definitions section in the recent revision history.

07/01/2025archived_previous_version

Archived previous policy version CSOZ6TN.Q.