RetiredUnitedHealthcarePolicy CS076LA.M

Manipulative Therapy (Louisiana)

State-specific UnitedHealthcare medical policy governing coverage and medical necessity of manipulative therapies (chiropractic and osteopathic) for Louisiana enrollees, including age-based criteria and technique-specific exclusions.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (Louisiana)

Policy CodePolicy CS076LA.M

Change TypeRetirement and content clarifications

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionFor enrollees under 21, obtain and document an EPSDT primary care referral before providing chiropractic manipulative treatment.

SourceLink

POLICY UPDATE CHANGES

Chiropractic manipulative treatment for enrollees under 21 years of age when medically necessary and upon referral from an EPSDT medical screening primary care provider.

Chiropractic services for adults age 21 and older to diagnose and treat neuromusculoskeletal conditions associated with the functional integrity of the spine are covered and considered medically necessary, including chiropractic spinal manipulation of up to five regions when included in the documented treatment plan.

Replaced wording to specify that osteopathic manipulative therapy (rather than general 'manipulative therapy') is proven and medically necessary for treating musculoskeletal disorders, except as noted.

Policy retired; Louisiana plan membership disenrolled on Apr. 1, 2026.

Retired Apr 1, 2026policy retirement date

Up to 5max spinal regions covered

Under-21

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EPSDT referral requirement

multiplesystematic reviews cited

Coverage Criteria and Evidence Summary

Chiropractic Services for Under 21 Years of Age

Covered chiropractic manipulative treatment for enrollees under 21 when ALL of the following are met

Under 21 Chiropractic EPSDT Referral: Chiropractic manipulative treatment for enrollees under 21 years of age is covered when medically necessary and upon referral from an EPSDT medical screening primary care provider.

Document EPSDT referral to support authorization and medical necessity.

Chiropractic Services for Adults Age 21 and Older

Covered chiropractic services for adults when ALL of the following are met

Adult Chiropractic Coverage: Chiropractic services to diagnose and treat neuromusculoskeletal conditions associated with the functional integrity of the spine are covered and considered medically necessary; chiropractic spinal manipulation of up to five regions is covered when included in the documented treatment plan.up to 5 regions

Initial visit must include a treatment plan (level of care with duration/frequency, treatment goals, and measures to assess effectiveness); follow-up visits must document progress and measures used to assess effectiveness.

Osteopathic Manipulative Services Coverage and Exclusions

Osteopathic manipulative therapy coverage stance

OMT for MSDs: Osteopathic Manipulative Therapy is proven and medically necessary for treating Musculoskeletal Disorders.

OMT Non-MSDs Not Medically Necessary: Manipulative Therapy (including craniosacral therapy, nonstandard techniques, and use for non-musculoskeletal disorders, prevention/maintenance/custodial care, TMJ disorder, and scoliosis) is unproven and not medically necessary.

Policy content mandated by Louisiana Department of Health lists specific exclusions.

Scoliosis — Insufficient evidence

Scoliosis

Scoliosis evidence summary: Available evidence for manual therapy (including CLEAR protocol) and spinal manipulation for adolescent and adult idiopathic scoliosis is insufficient to consider these procedures proven safe and effective.

Multiple systematic reviews and small trials with high risk of bias limit conclusions; prior authorization or justification may be required for such therapies.

Neck pain — Mixed evidence with some positive findings

Neck pain

Neck pain evidence summary: Systematic reviews and RCTs report manipulative therapy/OMT can reduce pain and disability in chronic non-specific neck pain, but heterogeneity and risk of bias limit certainty.

Some trials show benefit over exercise or control; evidence quality ranges from very low to moderate and further high-quality RCTs are needed.

Shoulder/Extremity — Adjunct benefit

Shoulder and other extremity disorders

Shoulder/Extremity evidence summary: Randomized trials and systematic reviews suggest manual therapy combined with exercise may improve pain, function, and range of motion for shoulder disorders compared to exercise alone or no treatment; long-term effects are uncertain.

Evidence supports adding manual therapy to exercise in some conditions (e.g., impingement, adhesive capsulitis) though study heterogeneity and bias limit confidence.

Hip/Knee OA and related contexts — Limited supportive evidence

Hip and Knee osteoarthritis / postoperative and gait contexts

Hip OA evidence summary: Exercise is supported for hip OA; limited low-quality evidence suggests manual therapy may provide short-term pain relief and improved function compared to minimal control.

Additional high-quality RCTs are needed to confirm benefit.

Knee OA evidence summary: Systematic reviews and RCTs report manual therapy/OMT combined with exercise can improve short-term pain and function in knee OA; long-term effects are uncertain.

Some trials show superiority of combined therapy over exercise alone but evidence is limited by small samples and short follow-up.

Postoperative/PD gait context: Small trials report potential short-term improvements in range of motion or postoperative recovery metrics with OMT, but studies are limited by single-session designs, heterogeneity, and lack of long-term follow-up.

Clinical relevance requires longitudinal studies.

Ankle/Foot/Hand — Adjunctive benefits reported

Ankle, foot, hand disorders

Ankle/Hand evidence summary: Randomized trials and systematic reviews show that adding manual therapy to exercise can improve outcomes (pain, stability, ROM) in recurrent ankle sprains and that manual/manipulative therapy can be equivalent to standard care for some foot disorders; evidence is limited in size and follow-up.

Short-term improvements reported; larger, longer-term trials recommended.

Condition-specific coverage considerations

Coverage considerations based on published evidence summarized in the document section

Knee OA: Manual therapy may improve self-reported knee function versus comparators; evidence for pain reduction is weaker and endorsement for functional performance was limited.

Systematic reviews/meta-analyses cite mixed quality evidence (Salahm et al. 2017).

Ankle and Foot: Manual therapy combined with exercise produced greater improvements in pain, function, strength, and ROM for recurrent ankle sprain and plantar heel pain compared to exercise or electrophysical agents alone; for hallux valgus, structured manual/manipulative therapy was equivalent to night splint in the short term.

Plaza-Manzano 2016; Cleland 2009; du Plessis 2011.

Headache: Spinal manipulation and mobilization can be effective for cervicogenic headache and may reduce migraine days and pain/intensity; effects versus other conservative care are often similar and evidence quality varies.

Systematic reviews/meta-analyses (Rist 2019; Coelho 2019) support short-term benefits but call for larger trials.

General coverage summary for non‑musculoskeletal/visceral indications

General coverage logic: Manual and manipulative therapies for non‑musculoskeletal, visceral, or immune‑related indications are not supported by consistent high‑quality evidence; coverage should require documentation of clinical rationale, failure of standard therapies, and prior authorization; therapies remain investigational for these indications.

Derived from multiple systematic reviews and RCT summaries showing lack of superiority to sham and insufficient evidence.

Coverage rationale and evidence synthesis

Summary conclusions based on reviewed evidence:

Overall efficacy conclusions: Systematic reviews and meta-analyses report no consistent, clinically important benefits of craniosacral therapy (CST) across musculoskeletal and non-musculoskeletal conditions; available evidence is limited by small trials, heterogeneity, and high/unclear risk of bias.

Supported by Ceballos-Laita et al. 2024 and Amendolara et al. 2024.

Conditions with preliminary positive but low-certainty findings: Some small RCTs and cohort studies report short-term improvements (e.g., infantile colic, migraine, HRV/parasympathetic activity), but these are limited by small size, methodological flaws, and potential placebo effects; findings require validation in larger, well-designed trials.

Examples include Castejón-Castejón 2019 and Cook et al. 2024.

Reliability and diagnostic use: Systematic review evidence finds no support for reliability of diagnoses made using CST techniques, limiting its role in diagnostic decision-making.

Supported by Guillaud et al. 2016.

Coverage Rationale — State-Specific and Non State-Specific

Covered when ALL of the following are met (state-specific highlights from Summary of Changes):

Chiropractic services for under-21 enrollees: Chiropractic manipulative treatment for enrollees under 21 years of age is covered when medically necessary and upon referral from an EPSDT medical screening primary care provider.referral from EPSDT provider

Document EPSDT referral and medical necessity; initial visit must include treatment plan as required by policy.

Chiropractic services for adults 21+: Chiropractic services to diagnose and treat neuromusculoskeletal conditions associated with the functional integrity of the spine are covered and medically necessary; chiropractic spinal manipulation of up to five regions is covered when included in the documented treatment plan.up to 5 spinal regions

Initial visit must include level of care (duration/frequency), treatment goals, and measures to assess effectiveness; follow-up visits must document progress and measures used.

The policy specifies that manual and manipulative therapies are not supported for non‑musculoskeletal disorders. Examples called out include asthma, otitis media, infantile colic, internal organ/visceral disorders, and similar indications where long‑term safety and effectiveness have not been demonstrated in the medical literature. These uses are considered unproven and not medically necessary absent high‑quality evidence and therefore are excluded from routine coverage.

When manual therapies are proposed for non‑musculoskeletal or visceral indications, the policy indicates coverage should only be considered in the context of rigorous justification: document the clinical rationale, prior standard treatments tried, objective outcome measures, and informed consent acknowledging limited evidence. Randomized trials of acceptable or high quality reviewed found no consistent superiority of spinal manipulation over sham for non‑musculoskeletal conditions, supporting a noncoverage stance for these indications.

The policy notes that codes flagged with an asterisk are not on the State of Louisiana Medicaid Fee Schedule and therefore are not covered by the Louisiana Medicaid Program. Inclusion of a code in the policy does not itself indicate coverage or a right to reimbursement; providers should verify state fee‑schedule applicability prior to billing.

Available evidence for use of manual therapy or spinal manipulation to treat adolescent or adult idiopathic scoliosis is insufficient to consider these procedures proven, safe, and effective. Systematic reviews and trials cited small sample sizes, methodological limitations, lack of controls, and high risk of bias, and therefore manipulative approaches (including CLEAR protocol or general spinal manipulation) are not supported as established therapy for idiopathic scoliosis.

The policy explicitly states that use of manual therapies for non‑neuromusculoskeletal conditions (for example, hypertension, asthma, infantile colic, otitis media and other internal organ disorders) has not been shown to provide long‑term safety or effectiveness in the literature. Consequently, these indications are considered unproven and not medically necessary unless stronger, high‑quality evidence becomes available.

Randomized clinical trials and systematic reviews summarized in the policy found that spinal manipulation for non‑musculoskeletal disorders did not demonstrate superiority over sham or control in high or acceptable quality trials. For this reason, spinal manipulation for the treatment or prevention of non‑musculoskeletal conditions is considered not medically necessary based on current evidence.

The policy describes craniosacral therapy (CST) as an unproven manual therapy technique with overall insufficient high‑quality evidence of efficacy. Importantly, the policy cautions that CST should not be used in place of conventional medical care; while CST may be benign as a complementary approach, using it as a substitute for evidence‑based treatments is not supported and may lead to noncoverage.

The policy identifies a set of services and techniques as unproven and not medically necessary, including manipulative therapies used for non‑musculoskeletal indications, craniosacral therapy, TMJ treatment using manipulation, scoliosis treatment by manual techniques, maintenance/preventive manipulative care, and nonstandard techniques (for example, applied kinesiology, NUCCA). Osteopathic manipulative therapy is specified as proven and medically necessary for musculoskeletal disorders; other listed services remain unproven and excluded except where the policy explicitly states otherwise.

The policy states that Manipulative Therapy is unproven and not medically necessary for non‑musculoskeletal indications and for specified techniques listed in the exclusions. It further notes that manipulative therapy intended for prevention, maintenance, or custodial care lacks sufficient evidence to be considered medically necessary, though some small subgroup findings exist and would require strong documentation and justification for any ongoing care.

Use of manual therapy, including spinal manipulation and protocols such as CLEAR, for adolescent and adult idiopathic scoliosis is characterized in the policy as controversial and unsupported by sufficient evidence. Multiple systematic reviews and trials reported contradictory results, methodological flaws, and small sample sizes, leading to the conclusion that these approaches are not established treatments for idiopathic scoliosis.

The policy concludes there is insufficient evidence to support manipulative therapies for maintenance or preventive care. While selected trials have reported benefits in narrow subgroups (for example, recurrent low back pain patients), overall findings are mixed and do not justify routine, ongoing maintenance manipulative therapy without documentation of initial favorable response and a clear rationale for continued care.

Systematic reviews and RCTs summarized in the policy found that spinal manipulation for non‑musculoskeletal disorders generally failed to demonstrate a clinically meaningful effect over sham or control. The policy therefore indicates such use lacks demonstrated effectiveness and is not considered medically necessary for these indications.

Craniosacral therapy is described as having limited and low‑quality evidence across musculoskeletal and non‑musculoskeletal conditions. Systematic reviews and meta‑analyses (including Ceballos‑Laita et al. and Haller et al.) found no consistent clinically important benefits and raised concerns about study heterogeneity, risk of bias, and unreliable diagnostic methods. As a result, routine coverage for CST is not supported.

Some small trials report preliminary short‑term improvements for select pediatric or symptom measures, but these studies are methodologically limited and their results are insufficient to change the overall not‑supported stance.

The policy delineates certain manipulative therapies as unproven and not medically necessary. It clarifies that Osteopathic Manipulative Therapy (OMT) is considered proven and medically necessary for treating musculoskeletal disorders (except where specific exclusions apply), while other named techniques or nonstandard methods (for example, craniosacral/Upledger Technique, applied kinesiology, NUCCA, and similar approaches) are listed among services not supported by sufficient evidence and are therefore excluded from routine coverage.

Procedure and Billing Codes

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

Documentation Required

Billing notes and provider actions

Provider action: Document medical necessity clearly — include initial assessment, diagnosis, objective findings (e.g., ROM, neurological exam), functional impairment, and a time‑limited treatment plan with measurable goals. For maintenance care (S8990), document why restorative treatment goals have been met and why continued care is medically necessary; otherwise S8990 is considered maintenance and may be denied. Provider action: For scoliosis, current evidence is insufficient to support routine spinal manipulation as effective treatment; document rationale and supporting evidence if manipulation is used for scoliosis management. Provider action: Spinal manipulative therapy (CMT/OMT) for non‑musculoskeletal indications may be denied. Ensure diagnosis supports a musculoskeletal condition and that treatment is consistent with the condition treated. Provider action: Stepwise care expectation — conservative care such as a supervised exercise program and other noninvasive therapies should be attempted before or in conjunction with manual therapy. Consider and document trials of exercise and other appropriate modalities prior to approving ongoing SMT. Provider action: Suggested step requirement — document at least one trial of structured therapeutic exercise or equivalent conservative management unless contraindicated or clinically inappropriate; include dates, frequency, response to therapy, and reasons for escalation to manual therapy.

Codes marked with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and therefore are not covered by the State of Louisiana.

Provider Requirements, Authorization, and Documentation

Prior Authorization

EPSDT referral and treatment-plan requirement for under‑21 chiropractic care

Chiropractic manipulative treatment for enrollees under 21 years must be provided upon referral from an EPSDT medical screening primary care provider; document the EPSDT referral when submitting for coverage.

Applicable procedure codes referenced for chiropractic/osteopathic services are listed in the policy and should be billed per contract.

Prior Authorization

Prior authorization recommended for scoliosis manipulative therapy

Available evidence for manual therapy and spinal manipulation for adolescent and adult idiopathic scoliosis is insufficient; prior clinical justification or prior authorization may be required when these interventions are requested.

Document objective scoliosis measures (e.g., Cobb angle) and prior conservative treatments to support any authorization request.

Background and Policy Status

Manipulative therapy is a manual‑therapy approach intended primarily for musculoskeletal disorders by applying hands‑on techniques to joints, soft tissues, and related structures. The policy summarizes evidence showing modest, usually short‑term benefits for certain spine and extremity conditions, while noting that adverse events are generally transient and minor. For non‑musculoskeletal indications, the evidence is limited or inconsistent and does not support routine coverage; documentation and prior authorization are recommended when such uses are requested.

Definitions and Terminology

Manipulative Therapy — definition entry

ExamplesIncludes chiropractic treatments, physical therapy techniques, massage therapy, spinal manipulation, mobilization, soft tissue techniques, and OMT/OMM.

Intended useUsed to treat musculoskeletal conditions affecting the spine or limbs by addressing joints, muscles, ligaments, discs, and other soft tissues.

Musculoskeletal Disorders — definition entry

DefinitionMusculoskeletal Disorders (MSDs): injuries 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).

ScopeEncompasses disorders of bones, joints, muscles, ligaments, and intervertebral discs affecting function and activity tolerance.

Clinical relevance

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (Louisiana)

Policy CodePolicy CS076LA.M

Change TypeRetirement and content clarifications

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionFor enrollees under 21, obtain and document an EPSDT primary care referral before providing chiropractic manipulative treatment.

SourceLink

On This Page

Temporomandibular Disorders: Evidence is mixed and insufficient to consider manual therapy definitively safe and effective for TMD; some trials show short-term benefits for pain or mouth opening but findings are limited by small sample sizes and heterogeneity.

Multiple RCTs and reviews 2018-2024 indicate need for further high-quality studies.

Preventive/Maintenance Manipulative Treatment: Evidence is insufficient to support manipulative therapy for prevention, maintenance, or custodial care; subgroup benefits were reported in select studies but not generalizable.

Eklund 2018/2019; Senna and Machaly 2011.

Non-musculoskeletal disorders: Long-term safety and effectiveness of manual therapies for non-musculoskeletal conditions (e.g., asthma, otitis media, infantile colic, hypertension) have not been demonstrated; available studies are limited and further high-quality trials are needed.

Hope-Bell 2024; Chow 2021.

Osteopathic manipulative therapy is specified as proven and medically necessary for treating musculoskeletal disorders, except as otherwise noted in the policy.

See policy for listed exclusions (non‑MSD indications, CST, nonstandard techniques, scoliosis, maintenance care limitations).

Prior Authorization

Prior authorization for maintenance/preventive manipulative care

Maintenance or preventive spinal manipulation lacks consistent evidence of broad benefit; prior authorization may be appropriate to demonstrate an initial favorable response and rationale for ongoing care.

When requesting ongoing maintenance care, document initial treatment response and patient subgroup characteristics that justify maintenance therapy.

Prior Authorization

Prior authorization recommended for non‑musculoskeletal indications

Manual therapies (SMT, OMT, CST, visceral manipulation) for non‑musculoskeletal or visceral indications are not supported by consistent high‑quality evidence; prior authorization is appropriate when these are requested to ensure clinical rationale and trial nature are documented.

Document prior treatments, objective outcome measures, and informed consent acknowledging limited and inconclusive evidence when seeking authorization.

Prior Authorization

Prior authorization may be required for CST and non‑regulated manipulative procedures

Craniosacral therapy and other manipulative procedures are described as procedures (not FDA‑regulated); where coverage is considered, the limited quality of clinical evidence means prior authorization may be required to ensure therapy is adjunctive and not a substitute for standard care.

Ensure documentation shows CST or other manual therapies are being used as adjunctive care and list concurrent evidence-based treatments.

Prior Authorization

EPSDT referral required for chiropractic care under age 21

For enrollees under 21 years, chiropractic manipulative treatment is covered only when medically necessary and upon referral from an EPSDT medical screening primary care provider; document the referral to support authorization and claims.

Include EPSDT provider name/date of referral in the patient record and authorization materials.

Step Therapy

Stepwise care: exercise before or adjunct to manual therapy for hip/knee OA

For hip and knee osteoarthritis, exercise therapy is supported as first‑line; manual therapy is frequently studied as an adjunct, so prior authorization or coverage decisions should reflect that exercise-based care is generally expected before or alongside manual therapy.

Document attempts at guideline-based therapeutic exercise and response prior to or concurrent with manual therapy requests.

Step Therapy

Stepwise care: therapeutic exercise before/with manual therapy

Evidence supports combining manual therapy with exercise; consider a stepwise approach beginning with therapeutic exercise and adding manual therapy if response is inadequate.

Authorization requests should state whether exercise therapy was provided and describe the response.

Step Therapy

Suggest step requirement: conservative care before manipulative therapy

Consider requiring documentation of prior guideline‑based conservative care (e.g., medical therapy, physiotherapy, therapeutic exercise) before approving manipulative therapy for visceral or non‑musculoskeletal complaints.

Provide records of prior conservative treatments and objective outcomes when seeking authorization for manipulative interventions for non‑MSK indications.

Step Therapy

Place manipulative therapy in guideline‑based treatment pathway

Clinical guidelines recommend manipulative therapy as a nonpharmacologic option for low back and certain spine‑related conditions after or alongside self‑care; include guideline‑based sequencing and prior self‑care measures in authorization documentation.

State where manipulative therapy falls in the treatment sequence and document prior self‑care and nonpharmacologic treatments tried.

Documentation Required

Required initial visit treatment plan and follow‑up documentation

The initial chiropractic visit must include a documented treatment plan specifying level of care (duration and frequency), treatment goals, and measures to assess effectiveness; follow‑up visits must document progress and the measures used to assess effectiveness.

Include duration/frequency, quantitative or qualitative outcome measures, and explicit treatment goals in the initial visit note.
On follow‑up visits, record progress relative to the stated measures and update the treatment plan as indicated.

Documentation Required

Document scoliosis outcomes with objective measures

When documenting treatment for scoliosis, include objective outcome measures such as Cobb angle, trunk morphology indices, spinal mobility, treatment frequency/duration, and relevant baseline characteristics (e.g., age, menarche/Risser) to support outcomes.

Provide pre‑ and post‑treatment Cobb angle measurements and any radiographic assessments used.

Documentation Required

Documentation required to justify maintenance manipulative care

For maintenance or preventive manipulative care, documentation should justify patient subgroup selection (e.g., dysfunctional subgroup) and demonstrate a prior favorable response to initial treatment to support ongoing care.

Record initial treatment response metrics and psychological/behavioral subgroup classification when relevant.

Documentation Required

Documentation expectations for non‑musculoskeletal/visceral use

When manual or osteopathic interventions are used for non‑musculoskeletal or visceral disorders, document the indication, prior treatments tried, objective outcome measures, and informed consent acknowledging limited and inconclusive evidence.

Include rationale for trialing the intervention and plans for objective outcome assessment.

Documentation Required

Suggested outcome measures (adapted MYMOP NRS) for CST/cohort data

Prospective cohort data submitted in the literature used adapted MYMOP NRS scores to record symptom intensity, functional disability, and quality of life before and after treatment; such outcome measures can be used when documenting effects of CST or related therapies.

Consider using validated symptom and function scales (e.g., MYMOP NRS) when reporting outcomes.

Denial Risk

Required visit documentation — missing plan may lead to denial

Initial visit must include a documented treatment plan with level of care (duration and frequency), treatment goals, and measures to assess effectiveness; failure to include these elements at the initial visit or to document progress on follow‑up visits may risk denial.

Ensure the treatment plan and progress measures are present in the medical record to support coverage and authorization.

Denial Risk

Scoliosis manipulative therapies have insufficient evidence — denial risk

Manual therapy and spinal manipulation for adolescent and adult idiopathic scoliosis, including protocols such as CLEAR, are unsupported by sufficient evidence and are at risk for denial when billed as proven treatments for scoliosis.

Provide robust objective outcomes and trial evidence if requesting coverage for scoliosis‑directed manipulative interventions.

Denial Risk

Denial risk when treating non‑musculoskeletal indications with manipulative therapy

Use of manipulative therapy for non‑musculoskeletal conditions lacks demonstrated long‑term safety and effectiveness; claims for such indications may be denied if unsupported by high‑quality evidence.

Examples of non‑MSK indications cited: asthma, otitis media, infantile colic, hypertension, primary dysmenorrhea, migraine.

Denial Risk

Potential denial for SMT used for non‑musculoskeletal indications

Randomized trials of acceptable or high quality found spinal manipulative therapy was not superior to sham for non‑musculoskeletal disorders; payers may deny SMT claims for non‑MSK indications based on lack of demonstrated effectiveness.

Cite high‑quality RCT evidence if arguing medical necessity for SMT in a non‑MSK indication.

Denial Risk

Do not substitute CST for conventional care — noncoverage risk

Craniosacral therapy should not be used in place of conventional medical care; where CST is submitted as a replacement for evidence‑based treatment, lack of demonstrated benefit could lead to noncoverage.

If CST is used as complementary care, document concurrent conventional treatments and rationale for adjunctive use.

Denial Risk

Missing treatment plan or progress documentation may result in denial

Failure to include a treatment plan at the initial visit (level of care with duration/frequency, treatment goals, and measures to assess progress) or failure to document progress and effectiveness measures on follow‑up visits may negatively affect coverage or lead to denial.

Verify that initial and follow‑up visit notes explicitly reference the treatment plan and measured progress before submitting claims.

MSDs are the primary indications for which osteopathic manipulative therapy and other manual therapies are considered proven or medically appropriate in this policy context.

Upledger Technique — definition entry

DefinitionUpledger Technique: a complementary, light-touch, whole-body craniosacral treatment technique developed by John E. Upledger, DO, OMM, intended to work with the craniosacral system to support the central nervous system and improve coping, stress management, and self-care.

ClassificationPresented in the policy as a named craniosacral technique added to the definitions section.

Evidence stanceDescribed as a complementary craniosacral, light-touch treatment; the policy includes Upledger Technique in the definitions but treats craniosacral therapies overall as unproven due to insufficient high-quality evidence.

Manual therapy / Manipulative therapy — definition entry

DefinitionManual therapy / Manipulative therapy: interventions that include spinal manipulation, mobilization, osteopathic manipulative treatment (OMT), chiropractic adjustment, soft tissue mobilization, and other hands-on techniques aimed at joints, soft tissues, and neural structures to improve function and reduce pain.

ComponentsMay involve joint mobilizations/manipulations, muscle energy techniques, soft tissue work, and techniques directed at nerve or joint structures often combined with exercise.

Evidence contextEvidence summarized in the policy shows modest short- to intermediate-term benefits for certain spine-related conditions but heterogeneity and risk of bias limit certainty for many indications (e.g., neck pain, scoliosis).

Scoliosis outcomes — definition entry

Common outcomesScoliosis outcomes commonly reported include Cobb angle, vertebral rotation angle, apical deviation, pelvic obliquity, spinal mobility, and quality of life measures.

Measurement examplesCobb angle change, trunk morphology indices (vertebral rotation, apical deviation), and functional measures such as spinal mobility and QOL questionnaires.

Evidence summaryAvailable evidence for manual therapy and spinal manipulation in adolescent and adult idiopathic scoliosis is insufficient to consider these procedures proven safe and effective; trials are small and at risk of bias.

Manual therapy / manipulative therapy — alternate definition entry

DefinitionManual therapy / manipulative therapy: interventions including mobilizations, manipulations, soft tissue mobilization, and other hands-on techniques often used adjunctively with exercise to address pain, range of motion, strength, and function in extremity and spine disorders.

Typical applicationsUsed in trials for shoulder, ankle/foot, knee, and hip disorders where it is frequently combined with exercise programs and may provide short-term adjunctive benefits.

LimitationsStudy heterogeneity, small sample sizes, and variable risk of bias across trials limit certainty about long-term effectiveness and generalizability.

Craniosacral Therapy (CST) — definition entry

DefinitionCraniosacral Therapy (CST): a manual therapy technique that uses light-touch manipulation of the craniosacral system; considered unproven due to insufficient high-quality evidence supporting clinical efficacy.

Evidence summarySystematic reviews and meta-analyses report no consistent clinically important benefits of CST across musculoskeletal and non-musculoskeletal conditions; available studies are limited by small size, heterogeneity, and high/unclear risk of bias.

Clinical recommendationCST should not be substituted for conventional medical care; where used, lack of demonstrated benefit may preclude routine coverage and prior authorization may be required when requested for nonstandard indications.

Procedure status — manipulative therapy and craniosacral therapy are procedures and not subject to FDA regulation

Regulatory statusManipulative therapy and craniosacral therapy are procedures and are not subject to FDA regulation.

Coverage implicationBecause these are not FDA-regulated devices or drugs, coverage determinations rely on clinical evidence quality rather than regulatory approval; prior authorization may be used to ensure therapies are adjunctive rather than replacements for standard care.

Upledger Technique — named technique added to definitions (duplicate inventory entry)

Definition addedUpledger Technique: defined in the policy as a complementary, light-touch craniosacral whole-body technique developed by John E. Upledger, intended to support the craniosacral system and central nervous system.

Policy noteThe Upledger Technique definition was newly added to the definitions section in the policy revision history.

Evidence contextWhile named in the definitions, craniosacral techniques including Upledger are treated as unproven overall due to insufficient high-quality evidence in systematic reviews and RCTs.