ModifiedUnitedHealthcarePolicy CS076TN.S

Manipulative Therapy (for Tennessee Only)

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This policy governs coverage of manipative therapy for UnitedHealthcare Medicaid and CoverKids members in Tennessee. It does not apply to CoverKids pregnant women age 19 years and older, who are directed to a separate benefit provision.

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ModifiedUnitedHealthcarePolicy CS076TN.S

Manipulative Therapy (for Tennessee Only)

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Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Tennessee Only)

Policy CodePolicy CS076TN.S

Change TypeModified

Effective DateSeptember 1, 2026

Next Review DateN/A

Key ActionEvaluate manipulation under anesthesia under the separate Manipulation Under Anesthesia policy for Tennessee.

SourceLink

POLICY UPDATE CHANGES

The policy added a reference link to the Tennessee CoverKids benefits rule.

The coverage rationale was revised to state that manipulative therapy is proven and medically necessary for musculoskeletal disorders except as otherwise noted in the policy.

Language concerning medical necessity clinical coverage criteria was revised.

The reference to InterQual LOC: Outpatient Rehabilitatory & Chiropractic was removed.

Language stating that osteopathic manipulative therapy is proven and medically necessary for musculoskeletal disorders except as noted in the policy was removed.

The definition of Upledger Technique was removed.

The description of services, clinical evidence, and references sections were updated to reflect current information.

The previous policy version CS076TN.R was archived.

TNApplicable state

MusculoskeletalPrimary covered indication

Not medically necessaryUnproven indications

InsufficientScoliosis evidence

1Prior policy version archived

Medical Necessity and Coverage Criteria

Medically necessary musculoskeletal treatment

Covered when the service is manipulative therapy for a musculoskeletal disorder, subject to the exclusions and limitations below.

Covered indication: Manipulative therapy is proven and medically necessary for treating musculoskeletal disorders.

Coverage remains subject to the policy's exclusions and applicable benefit requirements.

Unproven and not medically necessary services

Not covered as unproven and not medically necessary when provided for any of the following indications or techniques.

Unproven indications and techniques: Prevention, maintenance, or custodial care; craniosacral therapy; temporomandibular joint disorder; nonstandard techniques including applied kinesiology, neural organizational technique, or the National Upper Cervical Chiropractic Association process; nonmusculoskeletal disorders; or scoliosis.

The policy states that all other indications are unproven and not medically necessary due to insufficient evidence of efficacy.

Idiopathic scoliosis

Evidence-based coverage assessment for idiopathic scoliosis.

Insufficient evidence: The available evidence for manual therapy, including but not limited to the Chiropractic Leadership, Educational Advancement, and Research scoliosis treatment protocol, and spinal manipulation for adolescent and adult idiopathic scoliosis is insufficient to consider the procedure proven safe and effective.

Systematic reviews similarly conclude that available evidence does not permit conclusions regarding the efficacy of manual therapy, including spinal manipulation, for adolescent and adult idiopathic scoliosis.

Preventive Manipulative Treatment

Preventive, maintenance, or custodial manipulative treatment is not established as effective.

Insufficient evidence: Evidence is insufficient to conclude that manipulative therapy is effective for prevention, maintenance, or custodial care.

Additional research involving larger, well-designed studies is needed to establish safety and efficacy. Findings from maintenance-care analyses require validation and are not confirmatory.

Nonmusculoskeletal Disorders

Manipulative or manual therapy for nonmusculoskeletal disorders is not established as effective.

Nonmusculoskeletal indications: Available evidence has not demonstrated long-term safety and effectiveness for nonmusculoskeletal disorders, including asthma, otitis media, infantile colic, hypertension, primary dysmenorrhea, migraine, dizziness, chronic rhinosinusitis, and psychological or gastrointestinal conditions.

Some studies reported short-term or statistically significant findings, but evidence was limited by small samples, methodological variability, high risk of bias, lack of high-quality replication, or absence of clinically meaningful differences.

Neuroimmunoendocrine Effects

Use of spinal manipulation to prevent infectious disease or enhance immunity is unproven.

Neuroimmunoendocrine claims: No credible scientific evidence demonstrates that spinal manipulation has a clinically relevant effect on the immune system or prevents infectious disease.

The reviewed evidence included small studies and did not establish clinical benefit in symptomatic individuals.

Visceral Disorders

Evidence is limited and insufficient to conclude that manipulative therapy is effective for disorders of internal organs.

Visceral disorders: Available evidence is insufficient to establish the safety and efficacy of manipulative therapy for visceral or internal-organ disorders.

A small uncontrolled study and a randomized trial reported some statistical improvements, but limitations included small samples, lack of control in one study, and changes that were not clinically relevant to participants.

Visceral disorders

Visceral manipulation for disorders of the internal organs is not supported by sufficient evidence.

Insufficient evidence: Available evidence is limited and insufficient to conclude that manipulative therapy is effective for disorders of the internal organs.

Additional robust, high-quality studies are needed to establish safety and efficacy.

Craniosacral therapy

Craniosacral therapy is considered unproven.

Unproven therapy: Insufficient evidence supports the efficacy, effectiveness, or safety of craniosacral therapy; available studies have limitations in methodology, design, reporting, blinding, randomization, and treatment standardization.

Additional robust, high-quality studies are needed before clinical usefulness can be established.

Nonstandard manipulative techniques

Nonstandard manipulative techniques lack identified peer-reviewed evidence.

No identified evidence: Published peer-reviewed literature was not identified for applied kinesiology, the National Upper Cervical Chiropractic Association technique, or the neural organizational technique.

The policy does not establish efficacy or safety for these techniques.

Pediatric guideline restrictions

Pediatric manipulative therapy should follow the cited condition- and age-specific guideline distinctions.

Guideline-disfavored pediatric use: The guidelines do not recommend spinal manipulation or mobilization in infants; cervical or lumbar spine manipulation in children; or spinal manipulation and mobilization in infants, children, and adolescents for nonmusculoskeletal pediatric conditions such as asthma, attention-deficit/hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.

The guidelines state that spinal mobilization and manipulation may be appropriate in adolescents, spinal mobilization in children, and thoracic manipulation in children for neck-back pain only.

Manipulation under anesthesia is not addressed by this policy. Refer to the separate Manipulation Under Anesthesia (for Tennessee Only) Medical Policy for coverage consideration.

This policy does not apply to CoverKids pregnant women age 19 years and older. Refer to CoverKids, Chapter 1200-13-21.05: Benefits for the applicable benefit provision.

Manipulative therapy for prevention, maintenance, or custodial care is not supported by sufficient evidence to establish effectiveness, safety, or clinical usefulness. Additional well-designed research is needed before these uses can be considered established.

Spinal manipulation used to treat or prevent infectious diseases or to confer or enhance immunity is unproven. The available evidence does not demonstrate a clinically relevant effect on the immune system.

For pediatric care, guidelines do not recommend spinal manipulation or mobilization in infants, cervical or lumbar spine manipulation in children, or spinal manipulation or mobilization for nonmusculoskeletal pediatric conditions in infants, children, and adolescents. The guidelines indicate that spinal mobilization or manipulation may be appropriate in adolescents, spinal mobilization in children, and thoracic manipulation in children for neck-back pain only.

Manipulative therapy is considered unproven and not medically necessary when used for prevention, maintenance, or custodial care; craniosacral therapy; temporomandibular joint disorder; or nonstandard techniques such as applied kinesiology, neural organizational technique, or the National Upper Cervical Chiropractic Association process.

Manipulative or manual therapy is considered unproven and not medically necessary for nonmusculoskeletal disorders and scoliosis. Examples of nonmusculoskeletal indications include asthma, otitis media, infantile colic, and internal organ disorders.

Craniosacral therapy is considered unproven because the available evidence is limited and generally poor in methodological quality and study design, with diverse outcome reporting. These limitations prevent conclusions regarding its efficacy, effectiveness, or safety.

Evidence regarding visceral manipulation for internal-organ disorders is limited and insufficient to establish safety and efficacy. Reported improvements came from studies with limitations such as small samples, lack of a control group, and findings that did not establish clinically meaningful benefit; additional robust, high-quality studies are needed.

Applicable Procedure Codes

Applicable 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.
S8990	Physical or manipulative therapy performed for maintenance rather than restoration.

Provider and Billing Implications

Denial Risk

Avoid unproven or nonstandard indications

Coverage may be denied when manipulative therapy is provided for prevention, maintenance, or custodial care; craniosacral therapy; temporomandibular joint disorder; or nonstandard techniques such as applied kinesiology, neural organizational technique, or the National Upper Cervical Chiropractic Association process.

Denial Risk

Confirm the indication is within scope

Coverage may be denied for nonmusculoskeletal disorders, including asthma, otitis media, infantile colic, and internal organ disorders, and for scoliosis.

Note

Use the separate policy for manipulation under anesthesia

Manipulation under anesthesia is not addressed by this policy. Refer the service to the separate Manipulation Under Anesthesia policy for Tennessee.

Policy Background

Manipulative therapy is the therapeutic application of manual pressure or force in which a practitioner moves or manipulates one or more parts of an individual's body. It may address structural and functional issues involving bones, joints, tissues, and muscles and may include osteopathic manipulation, chiropractic manipulation, physical therapy, and massage therapy.

Key Definitions

Manipulative Therapy

DefinitionA therapeutic application of manual pressure or force in which a practitioner moves or manipulates one or more parts of an individual’s body to achieve and maintain health as part of a whole system of evaluation and treatment.

Clinical scopeMay be used to treat structural and functional issues in the body’s bones, joints, tissues, and muscles.

Included approachesIncludes osteopathic manipulative treatment, osteopathic manipulative medicine, manipulative and body-based practice, manual therapy, physical touch methods, chiropractic treatments, physical therapy, and massage therapy.

Musculoskeletal Disorders

DefinitionInjuries or conditions that originate from joints, muscles, ligaments, discs, or other soft tissues in the spine or limbs.

Clinical symptoms

Policy Summary

PayerUnitedHealthcare

PolicyManipulative Therapy (for Tennessee Only)

Policy CodePolicy CS076TN.S

Change TypeModified

Effective DateSeptember 1, 2026

Next Review DateN/A

Key ActionEvaluate manipulation under anesthesia under the separate Manipulation Under Anesthesia policy for Tennessee.

SourceLink

On This Page

Denial Risk

Idiopathic scoliosis may be denied

Manual therapy, including chiropractic scoliosis protocols and spinal manipulation, for adolescent or adult idiopathic scoliosis may be denied because the available evidence is insufficient to consider the procedure proven safe and effective.

Denial Risk

Do not bill maintenance or preventive manipulation as restorative care

Preventive, maintenance, or custodial manipulative therapy may be denied because the evidence is insufficient to establish effectiveness, safety, or clinical usefulness.

Denial Risk

Nonmusculoskeletal indications may be denied

Manipulative or manual therapy for nonmusculoskeletal disorders may be denied because high-quality evidence has not established benefit over sham or control treatment. Listed conditions include asthma, infantile colic, hypertension, otitis media, primary dysmenorrhea, and migraine.

Denial Risk

Do not use spinal manipulation for immunity or infectious-disease claims

Spinal manipulation used to treat or prevent infectious diseases or to confer or enhance immunity is unproven and may be denied.

Denial Risk

Visceral-disorder treatment may be denied

Visceral manipulation for disorders of internal organs may be denied because available evidence is limited and insufficient to establish safety and efficacy. Preliminary statistically significant findings were not shown to be clinically relevant or supported by controlled evidence.

Denial Risk

Craniosacral therapy is unproven

Craniosacral therapy is considered unproven because insufficient evidence supports its efficacy. Additional robust, high-quality studies are needed.

Denial Risk

Document caution for internal-organ indications

Visceral manipulation for disorders of the internal organs may be denied because the available evidence is limited and insufficient to establish effectiveness, safety, or efficacy.

Denial Risk

Avoid nonstandard techniques without supporting evidence

Nonstandard manipulative techniques may be denied because published peer-reviewed literature was not identified for applied kinesiology, the National Upper Cervical Chiropractic Association technique, or the neural organizational technique.

Denial Risk

Follow pediatric age- and condition-specific restrictions

For pediatric care, spinal manipulation or mobilization may be inconsistent with cited guidelines when performed in infants, when cervical or lumbar manipulation is performed in children, or when used for nonmusculoskeletal pediatric conditions.

Guidelines indicate that spinal mobilization and manipulation may be appropriate in adolescents, spinal mobilization in children, and thoracic manipulation in children for neck-back pain only.
Listed nonmusculoskeletal conditions include asthma, attention-deficit/hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.

Produce clinically relevant symptoms such as pain or numbness.

Functional limitationsMay cause limitations in performing daily activities.

Osteopathic Visceral Manipulation (OVM)

DefinitionOsteopathic visceral manipulation (OVM) is a manual treatment evaluated for functional constipation and chronic nonspecific low back pain.

Treatment schedule in cited trialTreatment was provided in 15-minute sessions once a week for 6 weeks.

Cited trial populationThe 2023 randomized controlled trial included 70 participants randomized 1:1.

Reported outcomeThe treatment group reported reduced pain and improved Oswestry Disability Index results after 6 weeks and at follow-up; the reported disability change was not clinically relevant to participants.

Craniosacral Therapy (CST)

DefinitionCraniosacral therapy (CST) is a manipulative or manual therapy.

Evaluated populationCST has been studied in adults and children with clinical conditions.

Evaluated scopeStudies evaluated CST for clinical outcomes across musculoskeletal and nonmusculoskeletal conditions, including any clinical outcome reported in eligible randomized controlled trials.

Evidence statusCST is considered unproven because insufficient evidence supports its efficacy; an updated meta-analysis of 24 randomized controlled trials found no significant effects overall.