UnitedHealthcare Manipulative Therapy Coverage Update

Coverage Criteria and Evidence

inv-01: Medically Necessary

Covered when ALL of the following are met:

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

Refer to Kansas Medical Assistance Chiropractic Fee-for-Service Provider Manual for chiropractic coverage specifics.

inv-02: Not Medically Necessary / Unproven

Unproven / Not Medically Necessary Indications: Osteopathic Manipulative Therapy is unproven and not medically necessary for: non-musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, internal organ disorders), prevention/maintenance/custodial care, craniosacral therapy (cranial manipulation/Upledger Technique), temporomandibular joint (TMJ) disorder, scoliosis, and manipulative services that utilize nonstandard techniques (e.g., applied kinesiology, neural organizational technique, NUCCA).

These indications may be denied as not medically necessary.

inv-03: Scoliosis: limited/suggestive evidence

Scoliosis (adolescent idiopathic scoliosis): evidence summary

Scoliosis evidence: Home-based scoliosis-specific exercises combined with side-alternating whole body vibration showed small group-level Cobb angle improvement in one small RCT; multiple systematic reviews conclude insufficient evidence to establish benefit of spinal manipulative therapy for adolescent idiopathic scoliosis due to small, biased studies.Cobb angle change reported: -2.3 degrees in intervention vs 0.3 degrees control

Evidence limited by small samples, methodological shortcomings, lack of recommended outcome reporting, and need for larger high-quality trials.

inv-04: Neck: short-term benefit with low certainty

Neck pain: evidence summary

Chronic neck pain: Systematic reviews and RCTs report manipulative/osteopathic interventions can reduce pain and disability in chronic non-specific neck pain versus exercise or control in the short term, but overall certainty is lowered by heterogeneity and risk of bias.chronic defined as >3 months in the cited meta-analysis

Some trials show short-term benefit; long-term effects and consistency across studies are uncertain.

inv-05: Shoulder: adjunctive benefit, inconsistent evidence

Shoulder disorders: evidence summary

Frozen shoulder/impingement/rotator cuff: Randomized trials and systematic reviews report manual/osteopathic therapies added to exercise may improve pain and range of motion versus exercise alone in some studies, but evidence quality is low and results are inconsistent; a Cochrane review found no clinically important differences for rotator cuff disease.improvements typically short-term; trials heterogeneous

Manual therapy may be considered adjunctive to exercise; further robust trials needed to confirm benefits and durability.

inv-06: Elbow/wrist/hand: short-term benefits reported

Elbow, wrist, and hand disorders: evidence summary

Lateral epicondyle pain and carpal tunnel: Systematic reviews indicate mobilization/manipulation can improve short- and intermediate-term pain and may improve grip strength for lateral epicondyle (tennis elbow); a quasi-controlled trial reported participant-perceived symptom and function improvement with OMT for carpal tunnel syndrome though objective nerve measures did not change.short-term <3 months; intermediate up to 6 months

Evidence is limited by small study sizes and low quality.

inv-07: Hip OA / gait: modest/uncertain benefits

Hip osteoarthritis and gait-related outcomes: evidence summary

Hip OA and Parkinson gait: Some RCTs suggest manual therapy may provide short-term pain and functional benefits in hip osteoarthritis and a single-session OMT study showed increased sagittal hip range of motion in Parkinson disease patients, but long-term clinical relevance and durability are unestablished.single-session increases reported; one older RCT reported maintained benefits to 29 weeks

Overall evidence modest; larger, longer-term RCTs are needed.

inv-08: Knee OA: adjunctive benefit with limited long-term data

Knee osteoarthritis: evidence summary

Knee OA: Systematic reviews and RCTs report that manual/osteopathic techniques combined with exercise may improve pain and function compared with exercise alone in some trials; study quality and follow-up duration vary and long-term durability is uncertain.improvements reported at immediate and short-term follow-ups

Larger, well-designed trials with longer follow-up are needed to confirm sustained benefit.

inv-09: Ankle/foot: evidence supports short-term benefit

Ankle and foot disorders: evidence summary

Ankle sprain, HAV, plantar heel pain: RCTs indicate manual therapy plus exercise can yield better short-term outcomes than exercise alone for recurrent ankle sprain; manual/manipulative therapy showed equivalent or superior short-term outcomes versus standard care in some trials for hallux valgus and plantar heel pain.improvements measured immediate to one month and up to six months

Larger studies with longer follow-up recommended to confirm findings.

inv-10: Headache: promising but preliminary evidence

Headache (cervicogenic and migraine): evidence summary

Cervicogenic headache: Systematic reviews and RCTs suggest manual therapy techniques (manipulation, mobilization, soft tissue) can be effective for cervicogenic headache, with combined techniques often superior to single techniques; effects are generally short-term and evidence limited by methodological issues.short-term improvements reported

Further high-quality studies needed to confirm long-term benefit.

Migraine: Meta-analyses of RCTs suggest spinal manipulation may reduce migraine days and pain/intensity, but results are preliminary and based on small trials; additional large, rigorous RCTs are warranted.meta-analysis included six RCTs (677 participants)

Methodological quality across trials is variable.

inv-11: Evidence summaries by condition

Evidence summaries relevant to coverage decisions:

Headache (cervicogenic, tension-type, migraine): Systematic reviews and meta-analyses report that manipulation/mobilization and other manual therapies can reduce pain, frequency, and disability in cervicogenic headache and may reduce migraine days/pain; effects are often short-term and quality of evidence is variable with risk of bias and small samples.

Combined manual therapy techniques may improve outcomes versus single techniques; further large high-quality RCTs are needed.

Temporomandibular Disorders (TMD/TMJ): Evidence is mixed: some RCTs and meta-analyses show manual therapy can reduce TMJ pain and improve mouth opening versus conservative care, but overall evidence is limited by small sample sizes, heterogeneity, and methodological limitations; some trials show no significant long-term advantage over therapeutic exercise.

Additional high-quality, long-term RCTs are needed to validate efficacy.

Preventive/Maintenance Manipulative Treatment: Evidence is insufficient to conclude benefit for prevention, maintenance, or custodial care; selected subgroups (e.g., patients with recurrent LBP who responded to initial care) may derive modest benefit but findings are subgroup-specific and not generalizable.

inv-12: SMT for non‑musculoskeletal disorders

Coverage stance reflected by the cited evidence:

SMT for non-musculoskeletal disorders: All high- or acceptable-quality randomized trials found spinal manipulative therapy was not superior to sham for treatment of non-musculoskeletal disorders (infantile colic, childhood asthma, hypertension, primary dysmenorrhea, migraine).evidence = no superiority

Global Summit systematic review concluded no evidence of effect.

inv-13: Immunity / neuroimmunoendocrine claims

Neuroimmunoendocrine claims:

Immunity claims for spinal manipulation: No credible scientific evidence that spinal manipulation has clinically relevant effects on the immune system.evidence = none

Rapid evidence review (Kawchuk et al., 2020) found no credible evidence; use of SMT to treat or prevent infectious disease is unproven.

inv-14: Visceral disorders / OMT

Visceral manipulation and OMT for visceral disorders (selected trials):

Visceral/OMT trial findings: Individual RCTs show mixed results: some small RCTs report statistically significant improvements for outcomes (e.g., GERD symptoms, constipation with chronic low back pain) but are limited by small size, short follow-up, or methodological flaws; other trials show no short-term benefit when added to standard care.mixed evidence

Authors consistently call for larger, higher-quality trials to establish clinical relevance.

inv-15: Craniosacral therapy (CST)

Craniosacral therapy (CST) evidence synthesis:

CST overall effectiveness: Multiple systematic reviews and meta-analyses (including 24 RCTs; 1,613 participants in one meta-analysis) conclude CST demonstrates no reliable significant effects for most studied indications; where subgroup effects exist they are tempered by high bias, heterogeneity, wide prediction intervals, and methodological limitations.evidence = insufficient/negative

Small, flawed RCTs report isolated positive results (e.g., infantile colic, migraine) but are at high risk of bias and require validation.

inv-16: Evidence quality and general conclusion

Summary of evidence-based stance from included reviews and trials

Overall evidence quality: Most randomized trials and systematic reviews are small, at risk of bias, and provide imprecise estimates; evidence for efficacy of CST and many non-MSD indications is insufficient to establish robust clinical benefit.

Further high-quality, larger RCTs with standardized protocols and longer follow-up are needed.

inv-17: Infantile colic

Condition-specific controlled trial evidence

Infantile colic RCT: Small unblinded RCT (n=58) reported reduced crying hours, improved sleep and colic severity with 1-3 CST sessions versus no treatment at day 24, but study limitations (unblinded, small size) require further investigation before clinical usefulness is proven.

Castejón-Castejón et al. 2022; results not generalizable without replication.

inv-18: Migraine

Condition-specific controlled trial evidence

Migraine RCT: Small RCT (n=50) reported reduced pain, frequency, disability and medication intake with a CST protocol versus sham after 4 weeks with effects maintained at 8-week follow-up; small sample and methodological limitations necessitate validation in larger trials.

Muñoz-Gómez et al. 2022; findings preliminary.

inv-19: Cohort outcomes

Observational findings

Primary care cohort: Prospective cohort (220 records) reported decreases in symptom intensity and disability after an average of 7 CST sessions; improvements were associated with patient expectation and therapist experience and only minor adverse events were reported.

Observational design limits causal inference; results exploratory.

inv-20: Systematic review synthesis

Systematic review conclusions

Reliability and efficacy reviews: Systematic reviews found no evidence supporting diagnostic reliability of CST and concluded very few well-conducted trials demonstrate clinical efficacy; low-quality studies and modest results are likely attributable to non-specific effects.

Guillaud et al. 2016 and subsequent technology assessments concluded insufficient evidence to support CST for diagnosis or treatment.

This policy does not address Manipulation Under Anesthesia. For coverage criteria related to that procedure, refer to the separate Medical Policy titled "Manipulation Under Anesthesia (for Kansas Only)."

Several conditions and techniques are identified as lacking sufficient, high-quality evidence to support coverage. Systematic reviews and trials for some indications (for example, idiopathic scoliosis and many craniosacral therapy studies) are small, heterogeneous, and at substantial risk of bias; as a result these interventions are described as unproven / not medically necessary and claims may be denied when billed as medically necessary without stronger supporting data and documentation of prior conservative management.

Manual and manipulative therapies have not demonstrated consistent long-term safety or effectiveness for non‑neuromusculoskeletal conditions such as hypertension, asthma, infantile colic, otitis media, and other internal organ disorders. While some small trials report short-term or biomarker changes, the clinical significance and durability of these findings remain unproven and additional high-quality randomized trials are needed.

Use of spinal manipulation to treat or prevent infectious disease or to claim enhancement of immunity is unsupported by credible scientific evidence. A rapid evidence review and systematic syntheses found no credible evidence that spinal manipulation confers clinically relevant immune benefits; therefore such uses are excluded from evidence-based indications.

International guidance from IFOMPT and IOPTP does not recommend spinal manipulation or mobilization for infants or for non‑musculoskeletal pediatric conditions (including infantile colic and otitis media). For pediatric care, follow applicable professional guidance and the policy’s exclusions; infant and non‑MSK pediatric indications are considered not medically necessary when unsupported by condition‑specific high‑quality evidence.

References to two retired Kansas‑only medical policies have been removed from the Related Policies section: Diagnostic Spinal Ultrasonography (for Kansas Only) and Neuropsychological Testing Under the Medical Benefit (for Kansas Only), both retired effective Sep. 1, 2025. The policy history reflects these removals.

The policy lists several indications and techniques that are considered not medically necessary / unproven, including: craniosacral therapy (cranial manipulation/Upledger Technique), temporomandibular joint (TMJ) disorder treatments by manipulation, spinal manipulation for scoliosis, and manipulative services using nonstandard techniques (e.g., applied kinesiology, NUCCA). It also states that manipulative therapies delivered for prevention, maintenance, or custodial care are not supported by sufficient evidence and may be denied.

For adolescent idiopathic scoliosis (AIS), systematic reviews and trials are small, methodologically limited, and inconsistent; reviewers concluded there is insufficient evidence to establish that spinal manipulative therapy is effective for preventing curve progression or improving Cobb angle, and further high‑quality studies are required before considering this a covered indication.

Evidence does not support routine use of manipulative therapy for prevention or long‑term maintenance. Systematic reviews and randomized trials indicate insufficient data to conclude effectiveness for preventive or custodial use; claims for maintenance care should be supported by documentation of an initial favorable response and a clear clinical rationale for ongoing treatment.

High‑quality randomized trials and a Global Summit evidence synthesis found spinal manipulative therapy was not superior to sham for several non‑musculoskeletal disorders (including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine). Consequently, SMT for non‑MSD indications is considered unsupported by current evidence and is not recommended as a covered indication.

Craniosacral therapy (CST) has been evaluated in multiple systematic reviews and randomized trials; overall the evidence is of low quality with high risk of bias and inconsistent findings. Systematic reviews conclude there is insufficient evidence to support CST for diagnosis or treatment across most conditions, and CST should not replace conventional medical care.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization for extended or evidence-limited use

Prior authorization may be required for uses that exceed usual visit counts, are for extended/maintenance therapy, or that are for indications with limited or mixed evidence. When requesting prior authorization, submit clinical justification that ties the requested service to a covered musculoskeletal diagnosis and documents prior conservative care and response.

Prior authorization likely for extended courses beyond initial acute/restorative treatment
Prior authorization likely when requesting maintenance/preventive care (see documentation requirements below)
Prior authorization likely for craniosacral therapy (CST) or other evidence-limited techniques

Prior Authorization

Prior authorization considerations for maintenance care

For maintenance care (MC) or ongoing preventive manipulative treatment, prior authorization considerations include demonstration of an initial clinically meaningful response to a defined acute/restorative course and documentation of the rationale for continuing care.

Applicable Procedure and HCPCS Codes

Applicable procedure/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.

Codes referenced implicitlymixed

not specified

No explicit CPT/HCPCS/ICD codes provided in these chunks; studies reference interventions generically (spinal manipulative therapy, OMT, manual therapy, mobilization).

Definitions and Terms

Manipulative Therapy — definition

DefinitionTherapeutic manual 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, manual therapy, and other manipulative and body-based practices.

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

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

Musculoskeletal Disorders (MSDs) — 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.

Context

Background and Scope

Manipulative therapies — including osteopathic manipulative treatment (OMT), spinal manipulative therapy (SMT), and chiropractic manipulative treatment (CMT) — encompass hands‑on techniques (spinal manipulation, joint mobilization, soft‑tissue techniques, and related approaches) directed at treating structural and functional issues of bones, joints, muscles, and soft tissues. Evidence summarized in this policy supports OMT/SMT/CMT as medically necessary for Musculoskeletal Disorders (MSDs), while indicating mixed, generally short‑term benefits and limited evidence for many other conditions. Applicable procedure codes referenced include CPT/HCPCS codes such as 98925–98929, 98940–98943, and S8990 for maintenance therapy (reference coding section for full list).

OpenPayer

Manipulative Therapy (for Kansas Only)

Coverage Criteria and Evidence

Provider Requirements, Prior Authorization, and Documentation

Applicable Procedure and HCPCS Codes

Definitions and Terms

Background and Scope

Policy Revision History