ModifiedUnitedHealthcarePolicy CS076NE.O

Manipulative Therapy (for Nebraska Only)

This policy governs coverage and clinical guidance for osteopathic and chiropractic manipulative therapies in the state of Nebraska, specifying medically necessary indications (primarily musculoskeletal disorders) and services considered not medically necessary.

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Nebraska Only)

Policy CodePolicy CS076NE.O

Change TypeMaterial and non‑material updates

Effective Date06/01/2026

Next Review DateN/A

Key ActionRefer prior authorization and medical necessity determinations for chiropractic manipulative therapy to Nebraska DHHS Code § 471-5-003.02 and document objective imaging or prior conservative care as applicable.

SourceLink

POLICY UPDATE CHANGES

Replaced instruction to 'refer to the Nebraska Department of Health and Human Services, Code § 471-5-003.02: Chiropractic Services for chiropractic treatment' with 'refer to the Nebraska Department of Health and Human Services, Code § 471-5-003.02: Chiropractic Services for medical necessity clinical coverage criteria for chiropractic Manipulative Therapy'.

Removed definition of 'Upledger Technique'.

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

Nebraskaapplies only to

MusculoskeletalPrimary covered indication

NonmusculoskeletalNot medically necessary

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98925-98943,97140,S8990Codes listed

ArchivedPrevious version

Coverage and Medical Necessity Criteria

inv-01: Medically Necessary Indications (Osteopathic Manipulative Therapy)

Covered when ALL of the following are met

Primary covered indication: Osteopathic Manipulative Therapy is proven and medically necessary for treating Musculoskeletal Disorders

See state-specific chiropractic criteria referenced separately

inv-02: Not Medically Necessary / Unproven Indications

Not medically necessary for the following indications

Unproven indications: Nonmusculoskeletal disorders (e.g., asthma, otitis media, infantile colic, internal organ disorders); prevention/maintenance/custodial care; craniosacral therapy (cranial manipulation/Upledger technique); temporomandibular joint disorder; scoliosis; manipulative services using nonstandard techniques (e.g., applied kinesiology, neural organizational technique, NUCCA)

These are listed as unproven due to insufficient evidence

inv-03: Condition-specific evidence and implied coverage criteria

Summary of coverage-relevant evidence and implied criteria for potential coverage decisions

Acute low back pain (≤6 weeks): SMT is associated with modest short-term improvements in pain and function based on moderate-quality evidence from RCTs; benefits are transient and heterogeneity is large.

Consider coverage for short-term symptomatic relief when documentation supports acute LBP and alternative conservative measures have been considered.

Pregnancy-related low back / pelvic girdle pain: OMT has moderate-quality evidence for decreasing pain and improving function during pregnancy; evidence is limited and further high-quality trials are recommended.

Coverage may be considered when obstetric/clinical documentation supports pregnancy-related LBP and expected benefit is described.

Scoliosis (adolescent and adult idiopathic): Evidence is insufficient to consider manual therapy or spinal manipulation proven safe and effective; small RCTs and case series report mixed results but are limited by small sample sizes and methodological issues.

Noncoverage or cautious, case-by-case authorization recommended; require objective imaging (Cobb angle) and clear clinical rationale.

inv-04: Evidence summaries by condition

Evidence summaries and conclusions by condition (clinical efficacy and limitations)

Knee osteoarthritis: Some RCT evidence (Altinbilek et al. 2018) suggests short-term improved pain and function when osteopathic/manual therapy is added to exercise; systematic reviews found improved self-reported function but less consistent pain reduction. Short-term follow-up limits assessment of intermediate and long-term outcomes; further high-quality studies needed.

Ankle and foot disorders: RCTs show that combining manual therapy with exercises or as part of multimodal care can yield greater short-term improvements in pain, function, ROM, and strength compared with exercises or splints alone; larger and longer studies are needed.

Headache (migraine, cervicogenic, tension-type): Systematic reviews/meta-analyses present mixed findings: migraine reviews report very low-quality evidence and no effect of SMT on several outcomes; for cervicogenic and tension-type headaches, manipulation/mobilization may be as effective as other conservative treatments in the short term but evidence quality limitations persist.

inv-05: Coverage criteria (general)

Covered when ALL of the following are met

Evidence requirement: High-quality, replicated RCT evidence demonstrating clinically meaningful benefit for the specific nonmusculoskeletal or visceral indicationexplicit replicated RCTs with clinically meaningful outcomes

Most conditions lack such evidence (see exclusions).

Appropriate conservative therapy: Standard medical or physiotherapy care has been tried and documented prior to the manual/visceral interventiondocumented prior treatments and response

Several trials used the manual therapy as adjunct to standard care.

Objective outcome measures and follow‑up: Objective baseline and follow‑up measures and adverse event monitoring must be documentedmeasures and duration per indication

inv-06: Not established as medically necessary / Unproven

Coverage stance and rationale

Overall evidence-based coverage stance: Craniosacral therapy is considered unproven due to insufficient, low-quality, and heterogeneous evidence; no conclusive efficacy demonstrated for musculoskeletal or nonmusculoskeletal conditions in high-quality RCTs and meta-analyses.

Multiple systematic reviews and meta-analyses report no reliable benefits or only limited/small effects tempered by high risk of bias and methodological limitations (see supporting chunks).

This policy designates manipulative therapies as unproven and not medically necessary for indications outside of musculoskeletal disorders. Examples explicitly listed include nonmusculoskeletal disorders (e.g., asthma, otitis media, infantile colic, internal organ disorders), prevention/maintenance/custodial care, craniosacral therapy, temporomandibular joint disorder, scoliosis, and manipulative services using nonstandard techniques (for example, applied kinesiology and other named approaches).

Manual therapy and spinal manipulation for adolescent and adult idiopathic scoliosis are not proven to be safe and effective based on the available literature. Systematic reviews and primary studies are limited in number and quality, and many chiropractic studies fail to report outcomes consistent with SOSORT/SRS recommendations, limiting interpretability and reproducibility.

Long‑term safety and effectiveness of manual therapies have not been established for non‑neuromusculoskeletal conditions. While some trials report short‑term symptom improvements, the evidence base lacks high‑quality, replicated long‑term randomized trials required to support routine coverage for conditions such as hypertension, asthma, otitis media, and infantile colic.

Higher‑quality randomized trials and systematic reviews have found no consistent superiority of spinal manipulation therapy (SMT) over sham for several nonmusculoskeletal disorders (including infantile colic, childhood asthma, hypertension, and primary dysmenorrhea). Claims that SMT confers clinically meaningful neuroimmunoendocrine or infectious‑disease protection are not supported by credible scientific evidence.

Craniosacral therapy (CST) is considered unproven due to insufficient, low‑quality, and heterogeneous evidence. Systematic reviews and meta‑analyses report methodological limitations and inconsistent outcome reporting, and no reliable conclusions of efficacy or safety can be drawn from the current data.

Contemporary professional guidance does not recommend spinal manipulation or mobilization for infants and children for nonmusculoskeletal indications. International guidance (IFOMPT/IOPTP) advises against these techniques for pediatric nonmusculoskeletal conditions such as infantile colic, otitis media, breastfeeding difficulties, autism spectrum disorder, and cerebral palsy.

The policy administrative updates include the removal of the separate definition for the 'Upledger Technique'; this technique is no longer listed as a distinct definition within the policy.

Osteopathic manipulative treatment (OMT) is described in this policy as unproven and not medically necessary for indications other than musculoskeletal disorders. The policy specifically excludes OMT for nonmusculoskeletal conditions and other listed indications unless evidence demonstrates clinically meaningful benefit for the specific nonmusculoskeletal or visceral condition.

Use of manual therapy or spinal manipulation solely for the treatment of idiopathic scoliosis (adolescent or adult) is unsupported by sufficient evidence and is therefore considered not medically necessary except in exceptional, well‑documented cases evaluated on an individual basis.

Preventive or maintenance manipulative therapy lacks sufficient evidence to support routine effectiveness. Trials that examined maintenance care report limited absolute benefit and methodological limitations; therefore, routine preventive manipulative treatment for asymptomatic or custodial care is not supported.

There is no credible evidence that spinal manipulation can prevent or treat infectious diseases or meaningfully enhance immune function. Rapid reviews and systematic assessments conclude that studies cited in support of immune or infection‑related benefits are small, methodologically limited, and do not demonstrate clinically relevant effects.

Manual therapies evaluated for infantile colic and many pediatric visceral conditions show inconsistent, low‑to‑moderate quality evidence from small trials. Available RCTs suggest possible modest short‑term symptom relief for colic with low‑force techniques, but methodological variability, small sample sizes, and limited adverse‑event reporting prevent generalization and routine coverage without higher‑quality replicated evidence or controlled trial enrollment.

Craniosacral therapy (CST) is labeled unproven and not supported as medically necessary for the indications studied because pooled analyses and systematic reviews report limited effect sizes, heterogeneous methods, and generally poor study quality. Prior authorization and careful review are advised if CST services are submitted for coverage.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization / coding guidance

Prior authorization may be required for manipulative therapies in accordance with benefit plan rules. Verify prior authorization requirements before providing services and include appropriate CPT/HCPCS coding on authorization requests and claims. When coding, reference the applicable OMT and CMT codes (e.g., 98925–98929, 98940–98943) and the maintenance code S8990 as appropriate. Coordinate with any applicable UnitedHealthcare prior authorization portals or vendor tools.

Affected procedure codes: 98925–98929 (OMT); 98940–98943 (CMT); S8990 (maintenance)
See Medical Policy titled Habilitation and Rehabilitation Therapy for guidance on CPT 97140 (manual therapy)

Note

State-specific prior authorization / medical necessity reference

For chiropractic manipulative therapy medical necessity criteria that are state-specific in Nebraska, refer to Nebraska Department of Health and Human Services, Code § 471-5-003.02: Chiropractic Services. State or contractual requirements govern coverage determinations and supersede this policy where they differ.

Procedure and Billing Codes

Referenced Procedure 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
97140	Manual therapy techniques (e.g., mobilization/manipulation), one or more regions, each 15 minutes

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Background and Rationale

Manipulative Therapy refers to hands‑on therapeutic techniques in which a practitioner applies manual pressure or force to move or manipulate body parts with the goal of treating structural and functional musculoskeletal conditions. Examples include osteopathic manipulative treatment (OMT), spinal manipulation therapy (SMT), mobilization, soft‑tissue techniques, and related manual approaches used primarily for musculoskeletal disorders.

Definitions

Manipulative Therapy — Definition

TermManipulative Therapy

DefinitionTherapeutic application of manual pressure or force in which the practitioner moves or manipulates one or more parts of the individual's body to achieve and maintain the individual's health; includes osteopathic, chiropractic, physical therapy, and massage manual techniques.

Scope/ExamplesUsed to treat structural and functional issues in bones, joints, tissues, and muscles (e.g., chiropractic treatments, physical therapy, massage).

Musculoskeletal Disorders — Definition

TermMusculoskeletal Disorders

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., ability to perform daily activities).

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Nebraska Only)

Policy CodePolicy CS076NE.O

Change TypeMaterial and non‑material updates

Effective Date06/01/2026

Next Review DateN/A

SourceLink

On This Page

Neck pain: For chronic neck pain, manipulative therapies and OMT show improvements in pain and disability in multiple RCTs and meta-analyses though heterogeneity and low study quality reduce confidence; data for acute neck pain are limited.

Consider coverage for chronic neck pain when supported by prior conservative care and documented functional impairment; acute presentations may need more conservative measures first.

Shoulder conditions (impingement, rotator cuff disease, frozen shoulder): Exercise is recommended as first-line; when exercise alone is inadequate, manual therapy plus exercise may provide additional short-term benefit in some trials though evidence quality is low.

Authorize manual therapy as adjunct to exercise therapy when documentation shows inadequate response to exercise alone.

Elbow, wrist, hand (lateral epicondyle pain, carpal tunnel): Mobilization/manipulation may improve short- and intermediate-term pain and grip strength in lateral epicondyle disorders; OMT showed participant-reported improvements in carpal tunnel symptoms though objective nerve testing did not change.

Consider short-term coverage when documentation supports diagnosis and prior conservative measures.

Hip and knee osteoarthritis: Some RCTs show OMT/manual therapy plus exercise can improve short-term pain and function versus exercise alone, but overall evidence quality is low to moderate and long-term benefit is uncertain.

Consider coverage of manual therapy as adjunct to exercise when documented trial of exercise is inadequate and functional goals are described.

Ankle and foot (sprains, hallux valgus): Small RCTs demonstrate that combining manual therapy with exercises can improve short-term pain, function, ROM, and strength compared with exercises alone; structured MMT protocols were equivalent to night splints for hallux valgus in short term.

Consider short-term adjunctive authorization when conservative measures are documented.

Temporomandibular disorders (TMD): Evidence is insufficient to consider manual therapy definitively safe and effective; some RCTs and meta-analyses report short-term pain and mouth-opening improvements but methodological limitations and heterogeneity require further high-quality trials.

Maintenance/preventive manipulative treatment: Maintenance care may reduce days with bothersome low back pain in selected subgroups who initially respond to care, but absolute reductions may not meet prespecified clinically meaningful thresholds and study limitations exist; evidence does not support routine preventive SMT for the general population.

Nonmusculoskeletal indications (e.g., infantile colic): Evidence is limited and mixed; a scoping review of infantile colic found seven RCTs suggesting modest short-term symptom relief with low-force manual therapies but methodological variability and small samples limit generalizability; long-term safety and effectiveness not established.

Many studies limited by short follow‑up and subjective outcomes.

Nebraska DHHS Code § 471-5-003.02: Chiropractic Services
In case of conflict, federal, state, or contractual requirements govern

Denial Risk

Services for nonmusculoskeletal disorders

Manual and manipulative therapies are considered unproven or not medically necessary for nonmusculoskeletal indications (for example, asthma, otitis media, infantile colic, visceral/internal organ disorders) due to insufficient high-quality evidence of efficacy and uncertain long-term safety. Do not rely on manipulative therapy alone for these conditions when submitting prior authorization requests or claims.

Examples of nonmusculoskeletal indications: asthma, otitis media, infantile colic, hypertension, gastrointestinal or visceral disorders
Studies of SMT/OMT for nonmusculoskeletal conditions show no consistent benefit; high-quality RCTs do not demonstrate superiority to sham in several conditions

Denial Risk

Coverage risk for unproven therapy

Certain therapies considered unproven (for example, craniosacral therapy and other nonstandard manipulative techniques) carry coverage risk and may be denied if submitted without strong supporting evidence and clear medical necessity documentation. Prior authorization may be recommended or required; claims for unproven services are at risk of denial.

Craniosacral therapy (CST) is considered unproven and may be denied without substantiating evidence
Nonstandard techniques (e.g., applied kinesiology, certain NUCCA processes) are listed as unproven

Step Therapy

Conservative management expected first

Conservative management (e.g., exercise therapy, standard rehabilitative care) is expected as first-line treatment for most musculoskeletal conditions. Manual therapies are generally considered adjunctive to, not a replacement for, guideline-recommended conservative care. Document prior trials of conservative therapy and clinical rationale for adding manipulative treatment when requesting authorization.

Document trials of exercise, physical therapy, and other conservative interventions prior to manipulative therapy when applicable
For shoulder and hip osteoarthritis and many other conditions, exercise is recommended first; manual therapy may be adjunctive

ContextPrimary covered indication for osteopathic and chiropractic manipulative therapies in this policy (Nebraska-specific).

Spinal manipulation therapy (SMT) — Definition

TermSpinal manipulation therapy (SMT)

DefinitionHands-on manual procedure often used for low back and neck pain; RCT evidence provides modest short-term improvements in pain and function for acute low back pain but does not support efficacy for many nonmusculoskeletal disorders.

Evidence noteModerate-quality evidence from RCTs shows modest short-term benefits for acute LBP; higher-quality trials found no superiority to sham for several nonmusculoskeletal indications.

Osteopathic manipulative treatment (OMT) — Definition

TermOsteopathic manipulative treatment (OMT)

DefinitionA set of manual techniques delivered by osteopathic practitioners aimed at treating musculoskeletal complaints; evidence suggests possible benefit for pregnancy-related low back pain and some nonspecific neck and musculoskeletal conditions, though overall study quality is frequently low.

Evidence noteSystematic reviews report moderate-quality evidence for OMT decreasing pain and improving function during pregnancy, but studies have small samples and limited long-term follow-up.

Manual therapy / SMT — Definition

TermManual therapy / SMT

DefinitionHands-on interventions including spinal manipulation, mobilization, soft tissue mobilization, and other manual techniques evaluated across RCTs and systematic reviews for effects on pain, function, range of motion, and related outcomes.

Clinical useOften used as adjunct to exercise and other conservative care; evidence and effect sizes vary by condition and follow-up duration.

Maintenance care (MC) — Definition

TermMaintenance care (MC)

DefinitionPeriodic manipulative or chiropractic care provided after an initial beneficial response, intended as tertiary prevention for recurrent or persistent low back pain.

Evidence noteTrials suggest MC may reduce days with bothersome LBP in selected subgroups (e.g., dysfunctional subgroup) but benefits are variable and not universally clinically meaningful.

Craniosacral therapy (CST) — Definition

TermCraniosacral therapy (CST)

DefinitionA low‑force manual therapy technique aiming to influence cranial and sacral dynamics and purportedly affect physical and autonomic conditions; current pooled evidence is inconsistent and CST is considered unproven.

Evidence noteSystematic reviews and meta-analyses (e.g., Amendolara et al. 2024) found no reliable overall benefits; methodological limitations and high risk of bias temper findings.

Osteopathic visceral manipulation (OVM) / visceral manipulation — Definition

TermOsteopathic visceral manipulation (OVM) / visceral manipulation

DefinitionManual techniques targeting visceral organs intended to affect visceral function and related musculoskeletal symptoms; evaluated for conditions such as constipation, GERD, dyspepsia, endometriosis, and pelvic organ disorders with mixed trial results and methodological limitations.

Evidence noteSmall RCTs report some statistically significant changes but clinical relevance and reproducibility are limited; further high-quality studies are needed.

Spinal manipulation therapy (SMT) — Nonmusculoskeletal disorders

TermSMT for nonmusculoskeletal disorders

DefinitionManipulative procedures directed at the spine when used to treat nonmusculoskeletal disorders (e.g., infantile colic, asthma, hypertension); higher-quality RCTs found no superiority to sham and overall evidence does not support efficacy.

Evidence noteSystematic reviews of acceptable/high-quality RCTs found no evidence of effect for SMT in multiple nonmusculoskeletal conditions; results challenge claims of physiologic organ effects from spinal manipulation.

Craniosacral Therapy (CST) — Technique and Purported Effects

TermCraniosacral Therapy (CST) — Technique & purported effects

TechniqueA low‑force manual/osteopathic technique intended to influence cranial and sacral dynamics, often applied as light touch to the skull and sacrum to affect structure and autonomic function.

Purported effectsClaimed to affect a variety of physical and autonomic conditions, but systematic reviews report insufficient evidence for reliable clinical benefits and questionable diagnostic reliability.