ModifiedUnitedHealthcarePolicy CS076ID.B

Manipulative Therapy (for Idaho Only)

State-specific UnitedHealthcare medical policy governing coverage and clinical criteria for manipulative therapy (including osteopathic and chiropractic techniques) for members in Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Idaho Only)

Policy CodePolicy CS076ID.B

Change TypeMaterial revisions: clarified OMT scope and added Idaho-specific criteria

Effective DateAugust 1, 2025

Next Review DateN/A

Key ActionRefer to the Idaho Medicaid Provider Handbook, Chiropractor for chiropractic manipulative therapy clinical coverage criteria when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to the Idaho Medicaid Provider Handbook, Chiropractor for medical necessity clinical coverage criteria for chiropractic Manipulative Therapy.

Replaced language to specify 'osteopathic Manipulative Therapy' as proven and medically necessary for treating Musculoskeletal Disorders (with exceptions noted) instead of the broader 'Manipulative Therapy'.

Removed reference link to the Medical Policy titled Diagnostic Spinal Ultrasonography (for Idaho Only) and Neuropsychological Testing Under the Medical Benefit (for Idaho Only) (retired Oct. 1, 2025).

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

Added definition of 'Upledger Technique'.

IdahoGeographic applicability

9 codesCPT/OMT & CMT codes listed

S8990

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No effectSMT immunity evidence

CS076ID.APrevious version

Coverage Criteria and Evidence Summary

Coverage stance — musculoskeletal vs non-musculoskeletal

Covered when ALL of the following are met

General stance: Osteopathic Manipulative Therapy is proven and medically necessary for treating Musculoskeletal Disorders; osteopathic Manipulative Therapy is unproven and not medically necessary for non-musculoskeletal 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, neural organizational technique, NUCCA).

Refer to the Idaho Medicaid Provider Handbook, Chiropractor for medical necessity clinical coverage criteria for chiropractic Manipulative Therapy.

Headache

Summary of effectiveness findings by condition

Headache — cervicogenic and tension-type: Manipulation and mobilization are as effective as other conservative treatments for cervicogenic headache; for tension-type headache manipulation/mobilization is more effective than comparative conservative care in the short term (up to 4 weeks) and similar to other interventions at three months. Evidence derives from systematic reviews including nine RCTs (793 participants) though only a minority of trials were low risk of bias and overall study quality is variable.short-term benefit up to 4 weeks

Evidence includes Coelho et al. (2019) and earlier syntheses by Bronfort/Clar noting variable certainty and need for higher-quality trials.

Temporomandibular Joint Disorders (TMD)

Temporomandibular disorders (TMD) — mixed and generally insufficient evidence

TMD — manual therapy outcomes: Randomized trials and systematic reviews report some short-term reductions in pain and improvements in maximal mouth opening with manual therapy (including upper cervical mobilization/manipulation, cranio-mandibular manual therapy, and combined approaches); however studies are small, heterogeneous, at risk of bias, and effects are often not sustained long-term. Larger, high-quality RCTs with longer follow-up are needed to validate clinical usefulness.evidence limited by small sample sizes and heterogeneity

Includes network meta-analysis (Al-Moraissi et al. 2024), multicenter RCT (Dunning et al. 2024), Lam et al. (2023) systematic review, and others noting methodological limitations.

Preventive Manipulative Treatment

Preventive manipulative treatment

Prevention/maintenance: Insufficient evidence supports manipulation for prevention, maintenance, or custodial care. Trials and reviews show mixed results and methodological limitations, and reported maintenance benefits have important risk-of-bias and dropout concerns.no proven preventive benefit

Systematic reviews (e.g., Chow et al. 2021) and RCTs (Senna & Machaly 2011) highlight limitations such as small samples, high dropout, lack of blinding, and uncertain attribution of benefit to manipulation versus non-specific effects.

Non-Musculoskeletal Disorders

Non-musculoskeletal disorders

SMT for non-musculoskeletal disorders: High-quality randomized trials and a Global Summit synthesis found that spinal manipulative therapy (SMT) was not superior to sham for treatment of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine; there is no evidence supporting SMT to prevent non-musculoskeletal disorders.no demonstrated benefit in RCTs of acceptable/high quality

Côté et al. (2021) Global Summit identified six RCTs (534 participants) of acceptable/high quality showing no effect; documenters recommend policymakers and payers consider this when setting coverage policy.

Coverage recommendations and evidence synthesis

Coverage stance based on available randomized trials and systematic reviews:

SMT for non‑musculoskeletal disorders: SMT is not supported by randomized trials as superior to sham for treatment of non‑musculoskeletal disorders (infantile colic, childhood asthma, hypertension, primary dysmenorrhea, migraine); policymakers, payers, and clinicians should consider this lack of effect when making coverage decisions.

Global Summit systematic review (Côté et al.) concluded no evidence of effect in acceptable/high quality RCTs.

SMT for immunity: There is no credible scientific evidence that spinal manipulation confers or enhances immunity; use of SMT to prevent or treat infectious diseases is unproven.

Rapid evidence review (Kawchuk et al., 2020) found no credible evidence of immune benefit.

Osteopathic visceral manipulation: Evidence for osteopathic visceral manipulation is limited and inconsistent: small RCTs report some short‑term statistical improvements on selected outcomes (e.g., pain, GerdQ), but clinical relevance and replication are lacking—consider investigational or not covered pending higher‑quality evidence.

Coverage Rationale and State-Specific Criteria

Coverage stance as revised in policy history

Osteopathic Manipulative Therapy - Covered: Osteopathic Manipulative Therapy is proven and medically necessary for treating Musculoskeletal Disorders except as noted in the policy.

Policy language was revised to specify osteopathic Manipulative Therapy as proven for musculoskeletal disorders (see policy history).

Other Manipulative Therapies - Not Proven: Manipulative Therapy (non-osteopathic) is unproven and not medically necessary for indications not listed as proven due to insufficient evidence of efficacy.

The policy distinguishes osteopathic OMT from other manipulative approaches when determining coverage.

State-specific (Idaho): Refer to the Idaho Medicaid Provider Handbook, Chiropractor for medical necessity clinical coverage criteria for chiropractic Manipulative Therapy.

State-specific criteria were added to the policy; follow the Idaho handbook for chiropractic determinations.

Per policy, Manipulative Therapy (osteopathic Manipulative Therapy/OMT) is considered proven and medically necessary for Musculoskeletal Disorders. Conversely, manipulative therapies are unproven and not medically necessary for non‑musculoskeletal disorders such as asthma, otitis media, infantile colic, and other internal organ disorders. High‑quality randomized trials and systematic reviews evaluating spinal manipulation for non‑musculoskeletal conditions have not demonstrated benefit over sham, and the document advises that this evidence be considered when setting coverage and reimbursement policy.

The policy notes that evidence is lacking or inconclusive for several specific indications. For idiopathic scoliosis, multiple systematic reviews found insufficient evidence to draw conclusions about efficacy of manual therapy including spinal manipulation. For some headache types, evidence syntheses report mixed findings: mobilization techniques have moderate positive evidence for cervicogenic headache, while cervical manipulation/mobilization for tension‑type headache and manipulation alone for conditions such as coccydynia, sciatica, and fibromyalgia remain inconclusive or unsupported.

Use of manual therapies, including spinal manipulative therapy (SMT), for non‑neuromusculoskeletal conditions (for example, hypertension, asthma, infantile colic, and otitis media) is not supported by sufficient evidence. Systematic reviews and acceptable/high‑quality randomized controlled trials found SMT was not superior to sham for these non‑musculoskeletal disorders, and the policy states that SMT has not been shown to prevent occurrence of such conditions.

The policy excludes techniques for which no published, peer‑reviewed literature was identified. Named examples include applied kinesiology, the National Upper Cervical Chiropractic Association (NUCCA) processes, and the neural organizational technique; these techniques are treated as unproven due to absence of identified evidence.

Non‑standard manipulative therapy techniques such as applied kinesiology, NUCCA, and the neural organizational technique lack identified peer‑reviewed publications in the policy's literature search. Because published evidence was not found, these approaches are considered unsupported and unproven for coverage purposes.

The policy specifies that Osteopathic Manipulative Therapy (OMT) is regarded as proven and medically necessary for Musculoskeletal Disorders, but it is unproven and not medically necessary for other indications outside musculoskeletal conditions, including those listed as non‑musculoskeletal, maintenance/preventive care, craniosacral therapy, TMJ disorder, scoliosis, and nonstandard techniques.

Some sections of the evidence summary present findings as lack of evidence or inconclusive results rather than explicit ‘‘not medically necessary’’ determinations. For example, systematic reviews of manual therapy for idiopathic scoliosis concluded evidence is insufficient to permit conclusions, and reviews of cervical manipulation/mobilization report inconclusive evidence for tension‑type headache; the policy therefore frames these as areas of limited or low‑quality evidence that do not support broader coverage.

A comprehensive Global Summit review and additional systematic reviews found no evidence that spinal manipulative therapy (SMT) is effective for management of several non‑musculoskeletal disorders (infantile colic, childhood asthma, hypertension, primary dysmenorrhea, migraine). The policy therefore states that SMT for non‑musculoskeletal disorders is not supported by the evidence.

The policy cites a rapid evidence review concluding there is no credible scientific evidence that spinal manipulation confers or enhances immunity; therefore, SMT for prevention or treatment of infectious diseases or for immune enhancement is considered unproven and not medically necessary given the lack of demonstrated effect.

Overall, manipulative therapies are considered unproven and not medically necessary for indications not explicitly listed as proven. The policy lists examples (non‑musculoskeletal disorders, preventive/maintenance care, craniosacral therapy, TMJ disorder, scoliosis, and nonstandard techniques) and treats approaches without identified peer‑reviewed literature as unsupported for coverage.

Coding and Billing

OMT / CMT CodesCPT

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.

Related CPT (clarification)CPT

97140

Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes. (See habilitation/rehab policy for guidance.)

HCPCSHCPCS

S8990

Physical or manipulative therapy performed for maintenance rather than restoration.

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Idaho-specific prior authorization / criteria source

This policy applies only in Idaho, including Idaho Medicaid Plus plans. For prior authorization and state-specific clinical coverage criteria for chiropractic manipulative therapy, refer to the Idaho Medicaid Provider Handbook, Chiropractor.

Applies to Idaho (including Idaho Medicaid Plus)
Check Idaho Medicaid Provider Handbook, Chiropractor for prior authorization/criteria

Denial Risk

Unproven / Not Medically Necessary Indications

Osteopathic and chiropractic manipulative therapies are considered unproven and not medically necessary for non‑musculoskeletal indications, prevention/maintenance/custodial care, craniosacral therapy (CST), temporomandibular joint (TMJ) disorder, scoliosis, and nonstandard techniques (e.g., applied kinesiology, NUCCA). Manipulation under anesthesia is addressed in a separate Idaho-only policy.

Background

Background: Manipulative Therapy (including osteopathic manipulative treatment, chiropractic, and related manual therapies) is a hands‑on approach used to address structural and functional issues of bones, joints, muscles, ligaments, discs, and soft tissues for musculoskeletal disorders. The policy distinguishes musculoskeletal indications—where OMT is considered medically necessary—from a range of non‑musculoskeletal or unproven uses which the policy classifies as not medically necessary due to insufficient evidence.

Definitions

Manipulative Therapy definition

DefinitionTherapeutic manual application of 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, chiropractic treatments, physical therapy, massage, and related manual therapies.

PurposeUsed to treat structural and functional issues of bones, joints, tissues, and muscles as part of a whole system of evaluation and treatment.

ExamplesOsteopathic manipulative treatment (OMT), chiropractic treatments, physical therapy, massage therapy.

Musculoskeletal Disorders definition

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 activities of daily living).

Policy Revision History and Changes

This policy revision archives the prior version (CS076ID.A) and includes material changes. Notably, state‑specific criteria for Idaho were added (referencing the Idaho Medicaid Provider Handbook, Chiropractor), and language was revised to narrow the proven coverage statement to osteopathic Manipulative Therapy for musculoskeletal disorders. Supporting clinical evidence and references were refreshed as part of the update.

Summary of policy changes: state‑specific insertions were added for Idaho, and terminology in the coverage rationale was narrowed to specify osteopathic Manipulative Therapy as the covered modality for musculoskeletal disorders. The update also refreshed cited evidence and archived the previous policy version; a definition for the Upledger Technique was added.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Idaho Only)

Policy CodePolicy CS076ID.B

Change TypeMaterial revisions: clarified OMT scope and added Idaho-specific criteria

Effective DateAugust 1, 2025

Next Review DateN/A

Key ActionRefer to the Idaho Medicaid Provider Handbook, Chiropractor for chiropractic manipulative therapy clinical coverage criteria when requesting coverage.

SourceLink

On This Page

Small, single-site trials with short follow-up limit conclusions.

Craniosacral therapy (CST): Systematic reviews and meta-analyses report no consistent, clinically relevant benefit of CST across musculoskeletal or non‑musculoskeletal conditions; study quality is poor and findings do not support effectiveness—CST is considered unproven.

Amendolara et al. (2024) and Ceballos‑Laita et al. (2024) concluded insufficient evidence of benefit.

Non‑standard manipulative techniques: Non-standard techniques (e.g., applied kinesiology, NUCCA, neural organizational technique) lack identified peer‑reviewed evidence and are unsupported.

No published literature identified in the document for these techniques.

Examples of unproven/not medically necessary indications: asthma, otitis media, infantile colic, internal organ disorders

Prevention, maintenance, custodial care

Craniosacral therapy (CST) and other nonstandard techniques

Temporomandibular joint (TMJ) disorder and scoliosis

Note

No explicit denial triggers provided

The source content does not list explicit denial triggers (e.g., single definitive billing or clinical trigger) but highlights areas with limited or negative evidence where coverage is unlikely. Reviewers and providers should use the documented evidence base (below) and plan/federal/state contractual terms when determining medical necessity.

No single explicit denial trigger is defined in this policy
Use evidence summaries and benefit language to determine coverage

Denial Risk

Denial risk for SMT for non‑musculoskeletal or immune indications

There is a notable denial risk for spinal manipulative therapy (SMT) when used for non‑musculoskeletal or immune/infectious disease indications. Systematic reviews and RCTs found SMT no more effective than sham for many non‑musculoskeletal conditions and no credible evidence that SMT enhances immunity.

SMT not shown superior to sham for infantile colic, childhood asthma, hypertension, primary dysmenorrhea, migraine, etc.
No credible evidence SMT confers or enhances immunity — denial risk for infectious disease/immune indications

Billing Rule

Coding and documentation references (CPT/HCPCS)

Coding and documentation references are provided for billing and clinical documentation. CPT code guidance includes CPT 97140 (manual therapy techniques) considerations and specific OMT/CMT CPT codes (98925–98929, 98940–98943). HCPCS S8990 is noted for maintenance rather than restoration.

CPT 97140 — manual therapy techniques (see Habilitation and Rehabilitation Therapy policy for Idaho)
OMT codes: 98925–98929
CMT codes: 98940–98943
HCPCS: S8990 — maintenance care (not restorative)

Note

No specific provider documentation or submission requirements stated

The policy does not specify additional plan-level provider submission requirements or documentation forms. Providers should follow standard claim submission rules and any Idaho plan-specific prior authorization processes referenced in the Idaho Medicaid Provider Handbook.

No unique submission form or extra provider documentation workflow is specified in this policy
Verify plan-specific prior authorization and submission requirements in Idaho Medicaid guidance

Documentation Required

Documentation of evidence and expected outcomes

When documenting treatments that are medically indicated, include the indication, objective baseline measures, treatment goals and expected outcomes, number of sessions, and response to prior conservative care. For visceral manipulation, document session frequency/duration and validated outcome measures; for SMT/CST include evidence rationale and trial-level outcome expectations.

Document diagnosis, baseline pain/disability scores, functional goals, and number/duration of sessions
Record prior conservative therapy (exercise, standard care) and response
For visceral manipulation: document session dates, duration, validated outcome measures, and clinical significance of change

Prior Authorization

Documentation and benefit verification

Benefit terms and federal/state/contractual requirements govern final coverage decisions. Verify member benefits and any plan exclusions before rendering or billing services. UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist in benefit determination.

Benefit confirmation required — federal/state/contract governs in conflicts
Check member benefits and prior authorization status before treatment
UnitedHealthcare may apply third‑party criteria (e.g., InterQual)

Step Therapy

No step therapy requirements described / Step therapy preference

There are no step therapy requirements described within this policy. However, the evidence and guidance consistently prefer exercise and other conservative care before manipulation for many musculoskeletal conditions.

No formal step therapy program specified in this policy
Clinical preference: trial of exercise/conservative care before manipulation

ScopeIncludes spinal and extremity disorders assessed and managed with manual and other conservative therapies.

Use in policyServes as the indication for which osteopathic Manipulative Therapy is considered proven and medically necessary (except as noted).

Upledger Technique / Craniosacral therapy definition

DefinitionA complementary, light-touch, whole-body technique developed by John E. Upledger that works with the craniosacral system to support the central nervous system; described as a craniosacral approach and explicitly listed in the policy as an unproven indication.

CharacteristicLight-touch manual therapy aimed at craniosacral rhythms and central nervous system support.

Policy noteUpledger Technique is referenced as a named craniosacral therapy approach and its definition was added to the policy.

manual therapy / manipulation / mobilization / OMT definitions

DefinitionHands-on interventions including spinal manipulation, joint mobilization, muscle energy techniques, osteopathic manipulative treatment (OMT), and other manual approaches evaluated for pain, function, range of motion, and quality-of-life outcomes.

Common componentsHigh-velocity thrusts, low-velocity mobilizations, soft-tissue work, and muscle energy techniques used alone or with other conservative care.

Evidence contextEvaluated across RCTs and systematic reviews for conditions such as neck pain, headache, and low back pain with variable quality of evidence.

Spinal manipulative therapy (SMT) / manual therapy definition

DefinitionHands-on techniques directed at the spine including high-velocity thrusts and mobilization techniques, plus related osteopathic manipulative techniques intended to treat joint and soft-tissue spinal dysfunction.

Intended outcomesAimed to improve pain, disability, function, and range of motion in spinal disorders.

LimitationsFor non‑musculoskeletal disorders, systematic reviews (Global Summit) found no evidence of benefit versus sham; preventive or immune-enhancing claims are unsupported.

Spinal Manipulative Therapy (SMT) definition

DefinitionManual therapy techniques aimed at treating spinal dysfunction (spinal manipulative therapy, SMT); evaluated for both musculoskeletal and non‑musculoskeletal outcomes.

Evidence summaryHigh-quality trials and a Global Summit synthesis indicate SMT is not superior to sham for multiple non‑musculoskeletal disorders; no credible evidence it enhances immunity.

Policy implicationSMT is considered effective for certain musculoskeletal indications but not supported for non‑musculoskeletal or preventive uses per policy evidence synthesis.

Osteopathic Visceral Manipulation (OVM) definition

DefinitionManual osteopathic techniques targeting internal organs intended to affect visceral function and related musculoskeletal symptoms.

Trial findingsSome small RCTs report short‑term statistical improvements on selected outcomes (e.g., pain, ODI, EMG measures), but clinical relevance, replication, and long‑term effects are limited or lacking.

Evidence cautionStudies are often small, single‑site, short follow‑up, and require higher‑quality replication before broader coverage is supported.

Craniosacral Therapy (CST) definition

DefinitionA manual therapy that claims to manipulate cranial and sacral rhythms and the craniosacral system to affect health outcomes.

Evidence summarySystematic reviews and meta-analyses (e.g., Amendolara et al. 2024) find insufficient, inconsistent evidence and no reliable, clinically significant effects across studied indications.

Policy stanceCST is considered unproven; additional robust, high-quality studies are needed to establish efficacy.

Upledger Technique (named CST approach)

DefinitionNamed craniosacral therapy approach developed by John E. Upledger described as a light-touch, whole-body technique working with the craniosacral system to support the central nervous system.

Policy noteUpledger Technique is explicitly referenced in the policy as a named CST approach and its definition was added in the policy revisions.

Clinical roleConsidered a complementary craniosacral method; policy lists craniosacral therapies (including Upledger Technique) as unproven pending higher-quality evidence.