ModifiedUnitedHealthcarePolicy CS076KY.09

Manipulative Therapy (for Kentucky Only)

State-specific UnitedHealthcare medical policy governing coverage and clinical criteria for manipulative therapy (chiropractic and osteopathic) in Kentucky; affects providers delivering chiropractic and osteopathic manipulative services to Kentucky members.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Kentucky Only)

Policy CodePolicy CS076KY.09

Change TypeState-specific updates and wording clarifications

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionObtain required prior authorization per InterQual when providing chiropractic or osteopathic manipulative treatments for musculoskeletal disorders.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to Kentucky Administrative Regulations (KAR) Title 907, Chapter 003, Regulation 125 for covered services and limitations of chiropractic services.

Replaced language indicating 'chiropractic Manipulative Therapy is proven and medically necessary for treating Musculoskeletal Disorders' with 'chiropractic Manipulative Therapy is medically necessary for treating Musculoskeletal Disorders'.

Replaced language regarding osteopathic manipulative therapy being 'unproven and not medically necessary for all other indications' with clarified wording 'osteopathic Manipulative Therapy is unproven and not medically necessary for all other indications ... due to insufficient evidence of efficacy'.

Added definition of 'Upledger Technique'.

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

KYState applicability

98925-98929, 98940-98943, S8990

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Coverage Criteria and Evidence-Based Conclusions

Coverage Criteria (Chiropractic and Osteopathic Manipulative Therapy)

Covered when ALL of the following are met

Chiropractic Manipulative Therapy is medically necessary for treating Musculoskeletal Disorders when clinical coverage criteria per InterQual® LOC: Outpatient Rehabilitation & Chiropractic are met.InterQual criteria

See InterQual reference

Osteopathic Manipulative Therapy - Covered Indications: Osteopathic Manipulative Therapy is medically necessary for treating Musculoskeletal Disorders.MSD diagnosis

Children and adults with MSDs

Osteopathic Manipulative Therapy - Not Medically Necessary for Other Indications: Osteopathic Manipulative Therapy is unproven and not medically necessary for non‑musculoskeletal 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, NUCCA).Non‑MSD indication or listed technique

Examples enumerated in policy

Scoliosis — evidence insufficient

Evidence synthesis findings by condition

Scoliosis: Evidence is insufficient to consider manual therapy, including CLEAR protocol approaches and spinal manipulation, proven safe and effective for adolescent and adult idiopathic scoliosis; available trials are small, heterogeneous, often at substantial risk of bias, and do not permit robust estimation of effect size.

Further high‑quality RCTs needed.

Neck — mixed but some positive evidence

Chronic non‑specific neck pain: Systematic reviews and RCTs report that manipulative therapy (including OMT) can reduce pain and disability compared with exercise or control in some studies, though heterogeneity and generally low quality of evidence limit certainty; document outcomes and duration when used.

Consider as an option; monitor outcomes.

Shoulder — adjunctive role for manual therapy

Shoulder conditions (frozen shoulder, impingement, rotator cuff disease): Some RCTs and systematic reviews report that manual therapy combined with exercise may improve pain and range of motion; exercise is the recommended first‑line treatment and manual therapy may be considered adjunctive.

Document prior exercise trial and response.

Elbow/Wrist/Hand — limited short-term benefits

Elbow, wrist, and hand disorders: Mobilization and manipulation may provide short‑ and intermediate‑term pain relief and improved grip strength for lateral epicondyle (tennis elbow); limited and variable data for carpal tunnel show symptom improvement without objective nerve conduction changes—evidence is limited in quantity and quality.

Document functional and objective testing (e.g., grip, nerve conduction) when used.

Hip/Knee OA — exercise first, manual therapy adjunct

Hip and knee osteoarthritis: Exercise therapy has the strongest evidence for short‑term pain benefit in hip and knee OA; some trials report that adding manual therapy or OMT to exercise can improve short‑term pain, function, or range of motion, but overall evidence quality is mixed and longer‑term benefits are unclear—manual therapy is an adjunct to, not a substitute for, supervised exercise.

Require documentation of prior/concurrent exercise therapy.

Ankle/Foot — supportive short-term evidence

Ankle and foot conditions: Small RCTs suggest manual therapy combined with proprioceptive/strengthening exercise may improve pain, function, strength, and ROM for recurrent ankle sprain and is equivalent to night‑splint care for mild–moderate hallux abducto valgus in the short term; larger and longer trials are needed.

Consider as part of multimodal rehabilitation.

Coverage-relevant evidence summaries

Summarized findings relevant to coverage determinations:

Knee osteoarthritis: Systematic reviews support manual therapy for improvement in self‑reported knee function; less consistent support exists for pain reduction (based on 12 studies with variable risk of bias).

Ankle and foot conditions: Small RCTs report benefit when manual therapy is added to exercises for recurrent ankle sprain and superiority of manual therapy plus exercise over electrophysical agents for plantar heel pain; evidence is limited by small samples and short follow‑up.

Headache (migraine, cervicogenic, tension‑type): Systematic reviews and meta‑analyses report spinal manipulation/mobilization may reduce migraine days and pain and can be effective for cervicogenic headache; evidence quality varies and findings are preliminary for migraine.

Temporomandibular disorders (TMD): Evidence is mixed; some meta‑analyses and RCTs report short‑term pain and function improvements with manual therapy or combined approaches, but overall evidence is limited by small trials and heterogeneity.

Evidence-based coverage stance

Coverage stance based on available evidence:

SMT for non‑musculoskeletal disorders: Randomized trials and systematic reviews of acceptable or high quality found no superiority of spinal manipulative therapy (SMT) over sham for several non‑musculoskeletal disorders (infantile colic, childhood asthma, hypertension, primary dysmenorrhea, migraine); SMT is not supported for these indications.evidence negative

Global Summit systematic review cited.

Spinal manipulation for immunity claims: No credible scientific evidence supports SMT to confer or enhance immunity; use to prevent or treat infectious disease is unproven.evidence negative

Rapid evidence review concluded no credible evidence.

Craniosacral therapy (CST): CST meta‑analyses and systematic reviews (including 24 RCTs) found no significant overall effects and insufficient evidence to support clinical usefulness.

Overall evidence conclusion

Summary of evidence‑based coverage considerations

Evidence summary: Multiple systematic reviews and meta‑analyses find no consistent, reliable clinical benefit of craniosacral therapy across indications; many trials are small, heterogeneous, and at high risk of bias, so CST lacks robust evidence of effectiveness.

See supporting systematic reviews and meta‑analyses.

Limited positive signals

Notable isolated findings (limited/low certainty)

Isolated/limited positive findings: Some small trials and analyses report short‑term physiologic changes (e.g., HRV) and symptom improvements in infantile colic and migraine, but these findings are limited by small sample sizes, high risk of bias, wide prediction intervals, and lack of replication; they are insufficient to establish general effectiveness.

Not sufficient to change coverage stance.

Coverage Rationale (summary)

Summary of coverage rationale updates (state-specific and non-state-specific):

Chiropractic Manipulative Therapy coverage statement: Chiropractic Manipulative Therapy is medically necessary for treating Musculoskeletal Disorders (policy language revised to remove the word 'proven'); providers must follow InterQual criteria and applicable Kentucky regulations (KAR Title 907, Chapter 003, Regulation 125) for covered services and limitations.

State‑specific instruction added.

Osteopathic Manipulative Therapy not medically necessary statement: Osteopathic Manipulative Therapy is unproven and not medically necessary for indications not listed as medically necessary due to insufficient evidence of efficacy; wording was clarified in this revision.

Refer to policy exclusions for enumerated indications.

Osteopathic Manipulative Therapy (OMT) is unproven and not medically necessary for non‑musculoskeletal disorders. The policy identifies examples including asthma, otitis media, infantile colic, and internal organ disorders, and specifies that OMT is not supported for indications outside musculoskeletal disorders due to insufficient evidence of efficacy.

Manual therapy and spinal manipulation for adolescent and adult idiopathic scoliosis have insufficient evidence to be considered proven safe and effective. Systematic reviews and small trials report inconsistent results, methodological limitations, and high risk of bias; therefore current data do not support routine coverage of scoliosis treatment using these manual techniques.

Manual therapies applied to non‑neuromusculoskeletal conditions (for example, hypertension, asthma, colic, otitis media) lack demonstrated long‑term safety and effectiveness. Multiple systematic reviews and meta‑analyses, including recent CST reviews, find limited or no reliable clinical benefit for these non‑MSD indications, and additional high‑quality trials are required before such uses can be considered medically necessary.

Use of spinal manipulation to treat or prevent non‑neuromusculoskeletal disorders — including claims that spinal manipulation confers or enhances immunity — is unsupported by credible scientific evidence. High‑quality randomized trials and rapid evidence reviews found no clinically relevant immune or disease‑prevention effects from spinal manipulative therapy, so such uses are considered unproven.

Clinical guidance advises against performing spinal manipulation or mobilization on infants for non‑musculoskeletal pediatric conditions (for example, infantile colic, breastfeeding difficulties, otitis media, asthma). The IFOMPT/IOPTP recommendations explicitly discourage these techniques in infants and children for non‑MSD indications.

Policy language was revised to remove the term 'proven' from the chiropractic coverage statement and to clarify the wording regarding osteopathic manipulative therapy. The revision retains that OMT is unproven and not medically necessary for indications outside musculoskeletal disorders, and adds state‑specific instruction for Kentucky regulatory reference.

Consistent with the updated wording, Osteopathic Manipulative Therapy continues to be described as unproven and not medically necessary for all indications outside musculoskeletal disorders because of insufficient evidence of efficacy. The policy clarifies this stance rather than asserting broader claims of proven benefit.

Current evidence does not support the use of manual therapy or spinal manipulation as an effective treatment for idiopathic scoliosis in adolescents or adults. Systematic reviews and available RCTs are small, heterogeneous, and at substantial risk of bias, so manual/manipulative approaches for scoliosis are not supported by sufficient evidence to recommend as standard therapy.

Use of manual and manipulative therapies specifically to treat non‑musculoskeletal disorders is unsupported by sufficient evidence of clinical effectiveness. Summaries of randomized trials and systematic reviews found no superiority of spinal manipulation over sham for several non‑MSD conditions, and overall long‑term benefit and safety remain unestablished.

Spinal manipulative therapy (SMT) as a primary treatment for non‑musculoskeletal disorders is not supported by the evidence and may be contraindicated as a substitute for conventional, evidence‑based medical care. High‑quality RCTs and consensus reviews report no reliable efficacy for SMT in treating non‑MSD conditions.

Craniosacral therapy (CST), including Upledger‑type techniques, is considered to have insufficient evidence of clinical benefit. Multiple systematic reviews and meta‑analyses (including analyses of 15–24 RCTs) conclude CST demonstrates no consistent or clinically relevant effects across the range of musculoskeletal and non‑musculoskeletal conditions studied, and therefore CST is not supported as medically necessary.

OMT is explicitly designated as unproven and not medically necessary for indications not listed as medically necessary in this policy. The statement reflects the policy authors' determination that available evidence is insufficient to support coverage for OMT outside approved musculoskeletal disorder indications.

Procedure and Billing Codes

Referenced 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.

Related CPT ClarificationCPT

CPT 97140

Manual therapy techniques (e.g., mobilization/manipulation), one or more regions, each 15 minutes (referenced in habilitation/rehabilitation policy).

inv-27: scoliosis Cobb angle — ranges and example mean reductions (key values)

Reported inclusion range (RCTs)Cobb angle 10–45° used for enrollment in at least one RCT (AIS participants).

Example mean reduction — Pu Chu et al. (retrospective)Mean Cobb angle reduced from 29.7° to 23.4° (average 21.2% correction) after chiropractic adjustments (small retrospective series).

Example mean reduction — Langensiepen et al. (RCT)Major curve in intervention group decreased by 2.3° (SD ±3.8) vs 0.3° in control over six months; statistically significant in subgroup before menarche.

Example reported change — Wenxia et al. (RCT)Trial enrolled AIS with Cobb 10–45° and measured pre/post Cobb angle as a primary outcome (reported in trial description).

inv-28: Guiding criteria sources — InterQual and ASAM referenced

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Guidance

Prior authorization per InterQual — Chiropractic and osteopathic manipulative treatments governed by InterQual LOC criteria. When InterQual criteria apply, follow InterQual for prior authorization determinations for outpatient rehabilitation and chiropractic services. If InterQual is not applicable for a specific presentation, UnitedHealthcare may apply policy-level guidance below or other plan-specific requirements.

Refer to InterQual® LOC: Outpatient Rehabilitation & Chiropractic for primary authorization criteria
If InterQual does not apply, use UnitedHealthcare Medical Policies, Coverage Determination Guidelines, and Utilization Review Guidelines as applicable

Prior Authorization

Scoliosis — Prior Authorization Advised

Scoliosis — prior authorization advised due to limited/low-quality evidence. The evidence for spinal manipulation and manual therapy for adolescent and adult idiopathic scoliosis is insufficient and inconsistent; prior authorization is recommended to ensure appropriate patient selection and documentation of prior conservative care and measurement of baseline Cobb angle and follow-up outcomes.

Background and Context

Manipulative therapy encompasses manual application of pressure or forces to joints, muscles, and soft tissues to address structural and functional problems. These techniques — including osteopathic and chiropractic manipulative treatments — are commonly used to manage musculoskeletal disorders and are described in the policy as interventions aimed at improving pain, function, range of motion, and related outcomes.

Definitions and Terminology

inv-54: 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 treat structural and functional issues; includes chiropractic, physical therapy, and massage therapy.

PurposeUsed to achieve and maintain patient health as part of a whole system of evaluation and treatment for bones, joints, tissues, and muscles.

ExamplesIncludes osteopathic manipulative treatment (OMT), chiropractic treatments, mobilization and other manual therapies.

inv-55: 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.

Policy Changes and Revision History

2026-01-01RevisionLatest

Coverage Rationale updated: state-specific instruction added to refer to Kentucky Administrative Regulations (KAR) Title 907, Chapter 003, Regulation 125 for chiropractic services and limitations; language revised to remove the word 'proven' from the Chiropractic Manipulative Therapy coverage statement; wording clarified for Osteopathic Manipulative Therapy not-medically-necessary statement due to insufficient evidence of efficacy.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Kentucky Only)

Policy CodePolicy CS076KY.09

Change TypeState-specific updates and wording clarifications

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionObtain required prior authorization per InterQual when providing chiropractic or osteopathic manipulative treatments for musculoskeletal disorders.

SourceLink

On This Page

Prior Authorization

Maintenance / Preventive Manipulative Care

Prior authorization advisable for maintenance/preventive manipulative care. Evidence for maintenance or preventive spinal manipulation is mixed and limited to select subgroups; when maintenance care is requested, prior authorization can help confirm the patient met criteria for an initial therapeutic response and that ongoing care is intended for tertiary prevention with documented expected benefit.

Confirm an initial course of therapy produced measurable benefit before approving maintenance care
Include treatment plan specifying frequency, duration, and clinical goals for maintenance visits

Prior Authorization

SMT for Non‑Musculoskeletal Indications

Prior authorization recommended for spinal/manipulative therapy (SMT) for non‑musculoskeletal indications — lack of credible supportive evidence. The literature shows high‑quality randomized trials generally do not demonstrate benefit of SMT for non‑musculoskeletal disorders (e.g., asthma, infantile colic, hypertension, otitis media). Prior authorization is recommended and denial is possible when SMT is sought to treat non‑musculoskeletal conditions.

Non‑musculoskeletal indications include but are not limited to asthma, otitis media, infantile colic, hypertension, primary dysmenorrhea, and prevention of infectious disease
High-quality RCTs and systematic reviews have not shown SMT is superior to sham for these conditions

Denial Risk

Insufficient Evidence / Denial Risk

Insufficient evidence for non‑musculoskeletal indications — denial risk. Because systematic reviews and RCTs have not demonstrated clinically relevant effects of SMT for many non‑musculoskeletal disorders, requests for manipulation to treat such conditions may not meet medical necessity and are at risk for denial.

Consider denial when SMT is requested primarily to treat non‑musculoskeletal disorders without strong supporting evidence
Payers, regulators, and clinicians should consider current evidence when developing coverage or reimbursement decisions

Denial Risk

Do Not Substitute for Conventional Care

Craniosacral therapy and other complementary techniques should not be used in place of conventional medical care. Hayes and multiple systematic reviews conclude CST and similar therapies lack reliable evidence of efficacy; they may be benign as adjuncts but should not replace standard care for treatable conditions.

When conventional therapies exist, CST or manipulation should be adjunctive, not a substitute
If a patient declines standard care in favor of CST/manipulation, document informed refusal and counsel regarding evidence limitations

Documentation Required

Documentation: Clinical Elements to Include

Suggested clinical documentation elements. To support medical necessity and authorization decisions, include baseline and follow‑up objective measures, symptom scales, and prior conservative care trials.

Baseline and post‑treatment measures (e.g., Cobb angle for scoliosis; pain scales such as NRS/VAS; disability indices like ODI, RMDQ, SPADI, LEFS)
Functional outcomes and quality of life measures where applicable (e.g., SF‑36, MYMOP)
Treatment specifics: technique, body regions treated, duration per session, frequency, total planned sessions

Documentation Required

Document Prior and Concurrent Conservative Care

Document indication and prior/concurrent conservative care. Authorization requests should show that appropriate conservative therapies were attempted or considered prior to manipulation for most musculoskeletal conditions, consistent with guideline‑aligned sequencing.

Record trials of exercise therapy, splints/bracing, pharmacologic management, electrophysical agents, or other standard conservative measures and dates/duration
State reason conservative care was inadequate or contraindicated when applicable

Documentation Required

Documentation Expectations: Manual / Visceral Therapies

Documentation expectations for manual and visceral therapies. For manual, visceral, or craniosacral therapies, document indication, specific treatment techniques, objective outcome measures, and follow‑up plan to demonstrate benefit or lack thereof.

Specify technique (e.g., OMT, CMT, visceral manipulation, craniosacral therapy), body regions treated, and CPT/HCPCS codes submitted
Provide objective pre/post measures (e.g., ROM, validated disability scores), number of sessions, and planned reassessment interval

Documentation Required