ModifiedUnitedHealthcarePolicy CS076.O

Manipulative Therapy

This UnitedHealthcare medical policy governs coverage of manipulative therapy (including osteopathic and chiropractic manipulative treatments and related manual therapies) for members; it defines covered musculoskeletal indications and lists exclusions and relevant codes.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy

Policy CodePolicy CS076.O

Change TypeClinical evidence and references updatedminor template and state-language removalsdefinition added

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionVerify plan-specific prior authorization rules and documentation when requesting coverage, and confirm the indication is a covered musculoskeletal disorder.

SourceLink

POLICY UPDATE CHANGES

Removed content/language pertaining to the state of Louisiana.

Removed reference links to retired medical policies: Diagnostic Spinal Ultrasonography and Neuropsychological Testing Under the Medical Benefit.

Removed content/language pertaining to the state of Mississippi.

Added definition of 'Upledger Technique'.

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

MSDsMSDs covered

Non-MSKNon-MSK not covered

CS076.OPolicy #

Codes

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.

mixed/lowEvidence quality

04/01/2026Recent revision

Coverage Criteria

inv-01: Covered — Musculoskeletal Disorders

Covered when ALL of the following are met:

Covered Indications: Manipulative Therapy is considered proven and medically necessary for treating Musculoskeletal Disorders (MSDs).

MSDs defined in Definitions; see clinical trials and reviews for specific MSDs such as acute/chronic low back pain, neck pain, and selected limb/foot disorders.

inv-02: Not Medically Necessary / Unproven

Not covered / Unproven when ANY of the following apply:

Not medically necessary / unproven indications: Non‑musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, internal organ/visceral disorders), prevention/maintenance/custodial care, craniosacral therapy (including Upledger Technique), temporomandibular joint (TMJ) disorder, scoliosis, and manipulative services using nonstandard techniques (e.g., applied kinesiology, NUCCA).

Scoliosis specifically has insufficient evidence to be considered proven safe and effective.

inv-03: Coverage-relevant evidence summaries

Evidence-informed coverage considerations derived from clinical studies and systematic reviews

Headache (migraine/cervicogenic/tension-type): Manual therapy including manipulation and mobilization may reduce pain and disability for cervicogenic headache and may reduce migraine days/pain; results vary by study quality and follow-up and are considered preliminary in some reviews.evidence strength variable

Multiple systematic reviews/meta-analyses report positive but sometimes low-quality evidence; further rigorous large RCTs are needed.

Plantar heel pain (ankle/foot): Manual physical therapy plus exercise demonstrated greater functional and pain benefits than electrophysical agents plus exercise in a 60‑participant randomized trial.single RCT evidence

Cleland et al. (2009) reported greater improvement in LEFS, FAAM and NPRS for MTEX versus EPAX.

Temporomandibular disorders (TMD):

inv-04: Spinal Manipulative Therapy (SMT) — non‑musculoskeletal disorders

Evidence‑based stance summaries from systematic reviews and meta-analyses

SMT for non‑musculoskeletal disorders: High or acceptable quality randomized trials found spinal manipulative therapy (SMT) is not superior to sham for several non‑musculoskeletal conditions (including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine); systematic reviews conclude no evidence of effect for SMT in these non‑musculoskeletal indications.

Global Summit review identified 6 RCTs (534 participants) of acceptable/high quality showing no effect; payers should consider this when making coverage/reimbursement decisions.

inv-05: Craniosacral Therapy (CST)

Craniosacral therapy evidence synthesis

CST effectiveness: Multiple systematic reviews and meta-analyses (including one pooling 24 RCTs with 1,613 participants) show no consistent, clinically relevant benefits of craniosacral therapy (CST) across musculoskeletal or non‑musculoskeletal conditions; methodological limitations, heterogeneity, and high risk of bias in primary studies preclude firm conclusions and CST is considered unproven.

Some physiologic signals (e.g., short‑term HRV changes) have been reported, but clinical relevance is uncertain; CST should not replace conventional care.

inv-06: Limited/conditional evidence

Selective positive/limited evidence

Potential efficacies: Moderate‑quality evidence indicates articular OMT techniques reduced dizziness disability, severity, and frequency in pooled analyses; small RCTs and meta-analyses report possible benefits of OMT/visceral techniques for some neonatal or infant outcomes and for select visceral/constipation outcomes, but findings are limited by small samples, heterogeneity, and risk of bias.

These signals are hypothesis‑generating and require further high‑quality replication before altering coverage stance.

Manipulative Therapy is considered unproven and not medically necessary for indications other than musculoskeletal disorders. Examples of exclusions include treatment of non‑musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, internal organ disorders), care provided for prevention, maintenance, or custodial purposes, and specific techniques such as craniosacral therapy (Upledger Technique). Temporomandibular joint disorder, scoliosis, and manipulative services using nonstandard techniques (for example, applied kinesiology or NUCCA) are also listed as unproven or excluded.

Evidence is insufficient or of low quality to support spinal manipulative or manual therapies for idiopathic scoliosis. Systematic reviews identified small, biased trials, case series, and inconsistent outcomes (including variable Cobb angle results) and concluded current data do not permit firm conclusions about efficacy; higher‑quality, controlled studies using recommended outcome reporting are needed.

The long‑term safety and effectiveness of manual therapies for non‑neuromusculoskeletal conditions (for example, hypertension, asthma, colic, and otitis media) have not been demonstrated in the medical literature; reported favorable outcomes are preliminary and require validation in larger, long‑term randomized controlled trials before being considered established.

Systematic reviews and meta-analyses indicate that spinal manipulative therapy (SMT) and craniosacral therapy (CST) lack consistent evidence of benefit when used to treat non‑musculoskeletal disorders. High‑ or acceptable‑quality randomized trials found SMT was not superior to sham for several non‑MSK conditions, and CST is described as unproven due to insufficient and low‑quality evidence.

Craniosacral therapy (CST) should not replace conventional medical care. Systematic reviews found CST diagnostic reliability and therapeutic effects are unsupported by high‑quality evidence, and Hayes and other assessments concluded CST shows no benefit over standard treatments for a range of conditions; therefore it must not be used as a substitute for established medical management.

Spinal manipulation and mobilization are not recommended for infants or for non‑musculoskeletal pediatric conditions. Professional guidance (IFOMPT/IOPTP) and systematic reviews report lack of benefit for pediatric non‑MSK indications (including infantile colic and otitis media) and support avoiding these techniques in infants and for non‑MSK pediatric conditions.

Policy content and template updates removed state‑specific language previously applicable to Louisiana and Mississippi; the current policy no longer contains those state‑specific statements.

Overall, manipulative therapy is proven and medically necessary for defined musculoskeletal disorders but is unproven for non‑musculoskeletal indications. Use of manual or manipulative techniques to treat conditions outside the MSD scope lacks robust evidence and is therefore not supported for coverage.

Reviewers did not always label the available studies with explicit 'not medically necessary' wording; rather, systematic reviews and evidence appraisals commonly concluded that evidence was insufficient to establish benefit (for example, in adolescent idiopathic scoliosis), which underlies the policy’s determination of those indications as unproven/not medically necessary.

Examples of non‑musculoskeletal conditions for which manual therapy is not supported by sufficient evidence include hypertension, asthma, infantile colic, and otitis media. The literature has not demonstrated long‑term safety or effectiveness for these uses and additional high‑quality trials are required before coverage can be justified.

There is no credible scientific evidence that spinal manipulation reliably treats or prevents non‑musculoskeletal disorders, including claims that SMT can confer or enhance immunity. Rapid reviews and systematic assessments found the studies cited for immune effects to be small, low quality, and not symptom‑based, leading to the conclusion that such immune claims are unproven.

Evidence is insufficient to support craniosacral therapy (CST) as a reliable diagnostic method or as an effective therapeutic intervention. Systematic reviews report poor diagnostic reliability, small and biased trials, and methodological limitations; CST’s observed effects may be attributable to non‑specific or placebo mechanisms rather than specific clinical efficacy.

Coding

Referenced procedure and HCPCS codesmixed

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.
S8990	Physical or manipulative therapy performed for maintenance rather than restoration.

Coding clarifications / cross-referenceCPT

97140

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

Provider Actions and Administrative Guidance

Billing Rule

Referenced codes (prior authorization / coverage relevance)

The following procedure and HCPCS/CPT codes are provided for reference only. Inclusion does not imply coverage or prior authorization — benefit determination and reimbursement are governed by the applicable federal, state, or contractual benefit terms and the fee schedule.

CPT/HCPCS/Coding lists are for claim processing reference only
Listing of a code does not guarantee coverage or payment

Prior Authorization

No explicit prior authorization/denial trigger

This policy text does not specify any explicit prior authorization requirements or automatic denial triggers. Providers should verify applicable benefit plan or state/federal requirements for any prior authorization obligations.

Background

Manipulative Therapy refers to manual applications of pressure or force to treat structural and functional problems of bones, joints, soft tissues, and muscles. Evidence supports its use for certain MSDs (for example, acute and chronic low back pain, neck pain and some pelvic/girdle conditions), while other indications remain unproven and are excluded from coverage.

Definitions

Manipulative Therapy — definition entry

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 achieve and maintain patient health; includes OMT, OMM, manipulative and body-based practice, manual therapy, and physical touch methods.

ExamplesChiropractic treatments, physical therapy, massage therapy; used to treat structural and functional issues of bones, joints, tissues, and muscles.

Musculoskeletal Disorders (MSDs) — definition entry

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 symptoms (e.g., pain, numbness) and functional limitations (e.g., impaired ability to perform daily activities).

Revision History

2026-04-01Template updateLatest

Template updated and content/language pertaining to the state of Louisiana was removed.

2025-09-01Related policies update

Removed reference links to retired medical policies: Diagnostic Spinal Ultrasonography and Neuropsychological Testing Under the Medical Benefit.

2025-07-01Template and content update

Template updated and content/language pertaining to the state of Mississippi was removed; definition of 'Upledger Technique' was added; Supporting Information, Clinical Evidence, and References sections were updated; previous policy version CS076.N archived.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy

Policy CodePolicy CS076.O

Change TypeClinical evidence and references updatedminor template and state-language removalsdefinition added

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionVerify plan-specific prior authorization rules and documentation when requesting coverage, and confirm the indication is a covered musculoskeletal disorder.

SourceLink

On This Page

Evidence is mixed and limited by small trials; some RCTs and meta-analyses show benefit of manual therapy or combination therapies (e.g., dry needling plus cervical manipulation) but larger high-quality trials are needed before definitive conclusions.

insufficient high-quality evidence

Dunning et al. (2024) showed benefit for a combination intervention but had design limitations.

Maintenance/preventive manipulative care: Maintenance chiropractic care may reduce days of bothersome low back pain for selected patients who respond to an initial course of care, but subgroup effects and methodological limitations limit generalizability.selected responders

Eklund et al. (2018) showed a modest reduction in days with bothersome LBP among responders; consider restricting MC to documented initial responders.

Non‑musculoskeletal conditions: Manual therapies lack sufficient evidence of long‑term safety and effectiveness for non‑neuromusculoskeletal conditions (e.g., asthma, hypertension, otitis media, infantile colic); current evidence is inconclusive and preliminary.not demonstrated

Systematic reviews report no consistent benefit and recommend against coverage for these indications absent high-quality supportive data.

No explicit prior authorization statements present in this section
Check specific plan terms for prior authorization needs

Denial Risk

Insufficient evidence may trigger denial

Services for indications with insufficient or conflicting evidence (for example, non‑musculoskeletal disorders, craniosacral therapy, preventive/maintenance care, TMJ treatment, scoliosis interventions, or other nonstandard techniques) are at risk for denial if submitted without strong supporting documentation demonstrating medical necessity and alignment with contract terms.

Non‑musculoskeletal indications (e.g., asthma, otitis media, infantile colic) lack high‑quality evidence and may trigger denial
Craniosacral therapy (CST) and maintenance/preventive manipulative care are highlighted as insufficient and at risk for noncoverage

Billing Rule

Coding reference and documentation note

Codes and coding guidance included in this policy are intended as documentation and billing references only. Presence of a code in this policy does not guarantee coverage, reimbursement, or prior authorization approval. Providers must bill according to payer billing rules and the member's applicable benefit contract.

Inclusion of a code does not imply right to reimbursement or guarantee claim payment
Refer to fee schedule and contractual benefit terms for coverage determination

Documentation Required

No specific documentation or record required

The inventory of studies and guidance does not establish any unique documentation form or additional record requirements beyond standard clinical documentation. However, when submitting for consideration, include relevant outcome measures, trial details, and rationale to support medical necessity.

No specific documentation form required beyond typical clinical records and outcome measures
Provide trial/intervention details and outcomes when seeking coverage for nonstandard or marginal‑evidence services

Documentation Required

Suggested outcome measures reported in literature

When reporting clinical outcomes to support medical necessity or demonstrate benefit, the literature emphasizes use of validated measures such as LEFS, FAAM, NPRS/NRS, migraine days, Neck Disability Index (NDI), Patient‑Specific Functional Scale (PSFS), and MYMOP (adapted 11‑point NRS). Include baseline and follow‑up scores where available.

Suggested outcome measures: LEFS, FAAM, NPRS/NRS, migraine days, NDI, PSFS, MYMOP
Report baseline and follow‑up measurements to support clinical benefit

Step Therapy

No step therapy requirements described

No step therapy requirements are described within this policy. Reviewers should confirm plan‑specific step therapy or conservative care prerequisites in the member's benefit contract before authorization or claim adjudication.

Policy does not establish step therapy rules
Check member contract for any step therapy or conservative care prerequisites

ScopeMSDs are the primary covered indications for manipulative therapy per this policy.

Craniosacral therapy (CST/Upledger Technique) — definition entry

TermCraniosacral therapy (CST) / Upledger Technique

DefinitionA noninvasive osteopathic/manual technique involving light touch to detect pulsations and rhythms of cerebrospinal fluid (CSF) and to gently work with the skull and spine intending to release restrictions without forceful manipulation; the Upledger Technique is a complementary, light-touch whole-body approach developed to work with the craniosacral system.

Policy stanceConsidered unproven due to insufficient, low-quality, and heterogeneous evidence; should not be used in place of conventional medical care.

spinal manipulative therapy / manual therapy / OMT — definition entry

TermSpinal manipulative therapy / manual therapy / OMT

DefinitionInterventions including spinal manipulation, mobilization, osteopathic manipulative treatment (OMT), muscle energy techniques, soft-tissue mobilization, Mulligan's SNAGs, translatory vertebral mobilization, and related hands-on manual techniques as described in trials and systematic reviews for neck, back, and headache conditions.

Clinical noteEvidence supports effectiveness for certain MSDs (e.g., acute/subacute low back pain, chronic neck pain when combined with exercise); effects vary by condition and study quality.

Manual therapy / Spinal manipulation — definition entry

TermManual therapy / Spinal manipulation

DefinitionTechniques encompassing spinal manipulative therapy, mobilization, soft-tissue mobilization, muscle techniques, Mulligan's SNAGs, and translatory vertebral mobilization used to address pain and functional limitations of the spine and limbs.

Evidence summarySystematic reviews report moderate evidence for manipulation/mobilization in acute low back pain and neck pain (often in combination with exercise); evidence quality and applicability vary by condition.

Dry needling plus upper cervical spinal manipulation — definition/example entry

Example interventionDry needling plus upper cervical spinal manipulation (combination therapy)

ContextCompared against interocclusal splint therapy, diclofenac, and TMJ mobilization in a multicenter RCT for temporomandibular disorder (TMD).

Study result noteIn the RCT (n=120), the combination produced greater reductions in jaw pain intensity and improved active pain-free mouth opening at three months versus the comparison group, but study limitations warrant validation in further trials.

Craniosacral Therapy (CST) — definition entry emphasizing unproven status

TermCraniosacral Therapy (CST)

Unproven statusCST is considered unproven: current evidence is insufficient, heterogeneous, and often low quality, and systematic reviews conclude no consistent, clinically relevant benefits; further robust studies are needed.

Clinical implicationCST may show short-term physiologic effects (e.g., HRV changes) in small studies, but clinical relevance and long-term benefits remain unclear; should not replace conventional care.

Osteopathic Manipulative Treatment (OMT) — definition entry

TermOsteopathic Manipulative Treatment (OMT)

DefinitionManual techniques applied by osteopathic practitioners, including high-velocity and articulation techniques (HVAT), soft-tissue massage, craniosacral therapy, visceral manipulation, and other hands-on methods intended to treat somatic dysfunction.

Evidence noteOMT has evidence for selected outcomes (e.g., reduced dizziness in some reviews; mixed evidence for non-musculoskeletal indications); trial quality and heterogeneity limit broad conclusions.

Craniosacral therapy (CST) — alternative phrasing/definition (cranial osteopathy)

TermCraniosacral therapy (CST) — alternative phrasing (cranial osteopathy)

DefinitionAlso referred to as cranial osteopathy; a light-touch manual therapy proposed to modulate the cranial rhythmic impulse and autonomic nervous system activity by working with skull and sacrum rhythms to release restrictions.

Evidence cautionSystematic reviews report unreliable diagnostic reliability and few well-conducted trials demonstrating clinical efficacy; positive findings may reflect non-specific/placebo effects.

Non-standard manipulative techniques — list of approaches lacking evidence (examples)

TermNon-standard manipulative techniques

Examples lacking peer-reviewed evidenceApplied kinesiology (including neural organizational technique), National Upper Cervical Chiropractic Association (NUCCA) techniques, and other approaches for which published peer-reviewed literature was not identified.

Policy implicationServices using these non-standard techniques are considered unproven and may be subject to denial due to lack of demonstrated effectiveness.

Upledger Technique — definition added to Definitions section

TermUpledger Technique

DefinitionA complementary, light-touch, whole-body treatment developed by John E. Upledger that works with the body's craniosacral system to support the central nervous system and promote stress management and self-care; added to the Definitions section of the policy.

ClassificationPresented within the policy as a form of craniosacral/manual light-touch therapy; evidence considerations for CST apply.