ModifiedUnitedHealthcarePolicy MMP227.12

Osteopathic Manipulations (OMT)

This UnitedHealthcare Medicare Advantage medical policy governs coverage, coding, and clinical rationale for osteopathic manipulative treatment (OMT) for Medicare Advantage members and describes when OMT is considered medically necessary and limitations. It applies to providers performing OMT and outlines applicable CMS guidance and relevant codes.

Policy Summary

PayerUnitedHealthcare

PolicyOsteopathic Manipulations (OMT)

Policy CodePolicy MMP227.12

Change TypeClinical evidence & references updated

Effective DateMay 1, 2025

Next Review Date

Key ActionDocument presence of somatic dysfunction (e.g., TART findings) in the medical record to support medical necessity for OMT.

SourceLink

POLICY UPDATE CHANGES

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

5OMT CPT codes listed

10Diagnosis codes listed

noneMedicare NCD exists

Numerous RCTsShort-term benefit evidence

64Chronic low back publications

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Clinical Evidence

Medical necessity criteria

Covered when ALL of the following are met

Coverage prerequisites: 1) Per applicable LCDs/LCAs where they exist; where no LCD/LCA exists, OMT is covered when medically necessary and performed by a qualified physician.

Refer to applicable LCDs/LCAs for state-specific requirements.

Documentation of somatic dysfunction: 2) Patient history and physical examination document the presence of somatic dysfunction of one or more regions (for example, TART findings: tenderness, asymmetry, restriction of motion, tissue abnormality).

Conventional documentation of somatic dysfunction must be present in the medical record; absence of such documentation is a denial trigger.

Service provided is OMT procedure: 3) The billed procedure is osteopathic manipulative treatment (OMT) — the manipulative treatment itself; evaluation and management (E&M) services may be billed separately when medically necessary and appropriately documented.

Routine planned follow-up OMT does not require a separate E&M unless the patient's condition has changed substantially.

Spine (low back) — evidence summary

Summary of conditions where manual/manipulative therapies showed evidence of benefit

Low back pain (acute and chronic): Systematic reviews and randomized trials report small to moderate, commonly short-term (up to 6 weeks) improvements in pain and function with spinal manipulation or manual therapy compared with exercise, usual care, sham, or other comparators; evidence quality ranges from low to moderate and heterogeneity is frequently noted.short-term (up to 6 weeks) improvements commonly reported

Some reviews report transient minor musculoskeletal harms; long-term efficacy remains uncertain and larger high-quality trials are recommended.

Neck — evidence summary

Evidence for neck pain

Chronic and non-specific neck pain: Meta-analyses and randomized trials found manipulative and osteopathic interventions reduced pain intensity and disability versus exercise or control in many trials among patients with chronic neck pain (>3 months), but high heterogeneity and low-to-very-low quality evidence limit certainty of effect estimates.chronic >3 months in cited reviews

Further research is needed to clarify patient selection and treatment characteristics contributing to heterogeneous results.

Neck pain combined with exercise: Randomized trials (for example, OMT combined with stretching/strengthening) showed greater reductions in pain and disability compared with exercise alone over short treatment periods (eg, 4 weeks), though long-term effects were not demonstrated.typically 4 weeks in cited RCTs

Limitations include difficulty blinding and limited long-term follow-up.

Shoulder — evidence summary

Evidence for shoulder conditions

Adhesive capsulitis / frozen shoulder: Multiple randomized trials and systematic reviews suggest mobilization and some manual techniques can improve pain and range of motion compared with comparators over treatment courses typically lasting several weeks (eg, 4–8 weeks), although study quality limitations and heterogeneity temper conclusions about long-term benefit.typically treatment regimens over weeks (eg 4–8 weeks)

Further high-quality trials with longer follow-up are needed.

Shoulder impingement / rotator cuff disease: Exercise is recommended as first-line; when manual therapy is combined with exercise it may provide additional short-term benefit, but higher-quality reviews report no consistent clinically important differences overall, indicating low certainty.short-term outcomes primarily assessed

Heterogeneity across trials and variable risk of bias noted.

Elbow, wrist, hand — evidence summary

Evidence for elbow, wrist, hand conditions

Lateral epicondyle pain / elbow disorders: Systematic reviews report short- and intermediate-term improvement in pain and, in some studies, improved grip strength with mobilization/manipulation versus comparators; the evidence base is limited by few, generally low-quality studies.<3 months and up to 6 months outcomes

Comparators included injection, exercise, modalities, sham, and no treatment.

Carpal tunnel syndrome: A quasi-controlled trial of weekly OMT for six weeks reported patient-perceived symptom and function improvement though electrophysiologic measures did not change; evidence is limited and follow-up short.6 weekly OMT sessions in cited trial

Interpret results cautiously due to study design limitations.

Lower extremity & postsurgical — evidence summary

Evidence for hip, knee, ankle/foot, and postsurgical management

Hip osteoarthritis and Parkinsonian gait: Some randomized trials report that single-session or short-course OMT or OMT plus cranial techniques can increase hip range of motion and improve gait kinematics in Parkinson's disease and may improve pain and function in hip OA; overall evidence is low quality and short-term.single-session or short course interventions in cited trials

Longitudinal studies over multiple visits are needed to determine clinical relevance and durability.

Knee osteoarthritis and postsurgical knee management: Randomized trials and systematic reviews indicate manual therapy or OMT combined with exercise can improve short-term pain and function versus exercise alone in knee OA and may aid postoperative recovery after total knee arthroplasty (improved ROM, reduced analgesic need); studies are small and longer-term outcomes are unclear.treatment durations commonly 2–5 weeks to 4 weeks in trials

Larger, longer-term randomized studies are recommended.

Clinical evidence summaries (no payer criteria)

Evidence summaries and guideline statements contained in these sections; no explicit coverage criteria provided in this document excerpt.

Knee OA evidence: Systematic reviews/meta-analyses (eg, Salamh et al. 2017) support manual therapy for improvement in self-reported knee function based on multiple studies, with lesser and inconsistent support for pain reduction; a subset of studies had low risk of bias/high treatment fidelity.

Evidence limited by small trials and variable quality.

Ankle/foot evidence: Randomized trials demonstrate manual therapy plus exercise improved outcomes versus exercise alone for recurrent ankle sprain and manual therapy plus exercise provided greater benefit than electrophysical agents for plantar heel pain.

Larger trials with longer follow-up are needed.

Hallux valgus evidence: A small randomized trial found manual/manipulative therapy equivalent to night splint for mild–moderate hallux valgus in the short term (30 patients).

Short-term data only.

OMT is not covered when the criteria for coverage are not met. Specifically, services are considered noncovered if the medical record does not contain conventional documentation of somatic dysfunction (for example, history and physical examination findings such as TART). Routine, previously planned follow-up OMT visits do not require a separate E&M unless the patient's condition has changed substantially or a new condition has developed.

Assessment and reporting of harms in trials of nonpharmacologic therapies including spinal manipulation and OMT were often suboptimal. Although systematic reviews generally did not identify serious harms, reported adverse effects were usually minor or transient (for example, superficial symptoms at the application site or temporary increases in pain). The limited and inconsistent harms reporting may constrain risk–benefit assessments used for authorization decisions.

Earlier comprehensive evidence syntheses did not find conclusive evidence that manipulation alone is effective for certain conditions. Specifically, Clar et al. (2014) and Bronfort et al. (2010) reported a lack of conclusive support for manipulation alone in coccydynia, sciatica, and fibromyalgia, and some reports did not find consistent evidence for cervical manipulation/mobilization for tension‑type headache. These inconclusive findings limit routine coverage recommendations for these indications.

Services that lack appropriate documentation of somatic dysfunction, or otherwise do not meet the stated indication criteria for OMT, will be considered not covered. Accurate contemporaneous documentation supporting the diagnosis and the appropriateness of OMT is required to substantiate coverage.

The evidence base for manual/OMT therapies is limited by heterogeneity across trials, variable study quality, and often small sample sizes. Many trials report only short‑term benefits with limited or absent long‑term follow‑up, which constrains confidence about sustained effectiveness and affects coverage and authorization considerations.

This item is reserved for a medium‑importance coverage consideration. No additional source text was provided to populate a specific statement.

Applicable Procedure and Diagnosis Codes

Applicable CPT codesCPT

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.

Applicable ICD-10-CM diagnosis codesICD-10

M99.00	Segmental and somatic dysfunction of head region.
M99.01	Segmental and somatic dysfunction of cervical region.
M99.02	Segmental and somatic dysfunction of thoracic region.
M99.03	Segmental and somatic dysfunction of lumbar region.
M99.04	Segmental and somatic dysfunction of sacral region.
M99.05	Segmental and somatic dysfunction of pelvic region.
M99.06	Segmental and somatic dysfunction of lower extremity.
M99.07	Segmental and somatic dysfunction of upper extremity.
M99.08	Segmental and somatic dysfunction of rib cage.
M99.09	Segmental and somatic dysfunction of abdomen and other regions.

Provider Requirements, Prior Authorization, and Documentation

Billing Rule

Procedure Coding Reference

Procedure coding reference: Osteopathic manipulative treatment (OMT) procedure and diagnosis codes for billing reference. Inclusion of a code in this policy does not guarantee coverage or payment; verify member-specific benefits and any other applicable policies.

CPT: 98925 — OMT; 1-2 body regions
CPT: 98926 — OMT; 3-4 body regions
CPT: 98927 — OMT; 5-6 body regions
CPT: 98928 — OMT; 7-8 body regions
CPT: 98929 — OMT; 9-10 body regions
ICD-10: M99.00–M99.09 — Segmental and somatic dysfunction codes (head, cervical, thoracic, lumbar, sacral, pelvic, lower extremity, upper extremity, rib cage, abdomen/other)

Background and Scope

Osteopathic manipulative treatment (OMT) refers to a set of hands‑on manual techniques performed primarily by osteopathic physicians to address somatic dysfunction—altered function of skeletal, arthrodial, myofascial, vascular, lymphatic, and neural elements. Common OMT techniques include muscle energy, high‑velocity low‑amplitude (HVLA) thrusts, counterstrain, myofascial release, visceral, and craniosacral approaches. Diagnosis of somatic dysfunction typically uses the TART framework (tenderness, asymmetry, restriction of motion, tissue abnormality).

Definitions and Terminology

Somatic dysfunction / OMT — definition key/value

DefinitionImpaired or altered function of related components of the somatic system (skeletal, arthroidal, and myofascial structures, and related vascular, lymphatic, and neural elements).

Diagnostic featuresIdentified by TART findings: tenderness, asymmetry, restriction of motion, and tissue abnormality.

Clinical significanceSomatic dysfunction in one region can create compensatory dysfunction in other regions and may manifest in musculoskeletal or visceral presentations.

Source contextDefined in the Glossary of Osteopathic Terminology and cited in AOA guidance as treatable with OMT.

Spinal manipulative therapy (SMT) / spinal manipulation — definition/key points

Definition

Policy Summary

PayerUnitedHealthcare

PolicyOsteopathic Manipulations (OMT)

Policy CodePolicy MMP227.12

Change TypeClinical evidence & references updated

Effective DateMay 1, 2025

Next Review Date

Key ActionDocument presence of somatic dysfunction (e.g., TART findings) in the medical record to support medical necessity for OMT.

SourceLink

On This Page

Ankle and foot (sprains, plantar heel pain, hallux valgus): Randomized trials show that adding manual therapy to proprioceptive/strengthening exercises or to exercise produced greater improvements in pain, function, ROM and strength for recurrent ankle sprain and plantar heel pain; a small trial found manual therapy equivalent to night splint for mild–moderate hallux valgus in the short term.4 weeks protocols and follow-up up to 1 month or 6 months depending on study

Larger studies with longer follow-up are needed.

Headache evidence: Systematic reviews and meta-analyses indicate spinal manipulation/mobilization may reduce migraine days and pain and can be effective for cervicogenic headache; overall evidence quality varies and further large RCTs are warranted.

Some reviews report low overall evidence or methodological limitations.

Guideline support (OMT): AOA (2016) guideline supports use of OMT for nonspecific acute and chronic low back pain, and ACP/APS guidelines recommend manipulative therapy as a nonpharmacologic option for acute, subacute, and chronic low back pain.

Guidelines call for further larger RCTs to strengthen evidence and clarify long-term effects.

Prior Authorization

Prior Authorization Guidance

Prior authorization may be required for OMT depending on the member's plan and delegate rules. When prior authorization is required, it should document the medical necessity of OMT, including the presence of somatic dysfunction and relevant clinical course. Evidence supports short-term benefits for certain conditions (e.g., acute and chronic low back pain, pregnancy-related LBP), but heterogeneity and limited long-term data may influence authorization decisions.

Document indication and clinical rationale for OMT in the prior authorization submission
Include duration of symptoms, prior conservative therapies, and treatment goals
Be aware that evidence limitations (heterogeneity, limited long-term follow-up, variable harms reporting) may affect authorization outcomes

Documentation Required

Required Clinical Documentation

Required clinical documentation: Coverage requires conventional documentation of somatic dysfunction. Medical records must include history and physical findings consistent with somatic dysfunction (for example, TART characteristics — tissue texture change, asymmetry, restriction of motion, tenderness) and physician assessment linking OMT to the diagnosis.

Document specific somatic dysfunction region(s) and objective exam findings
Record reason for OMT, how many body regions treated, and relationship to member's condition
Evaluation & management (E&M) services must be documented separately when billed

Documentation Required

Required Outcome Documentation

Required outcome documentation: Trials of OMT used validated outcome measures to demonstrate clinical response. When available, include baseline and follow-up scores to support medical necessity and continuation decisions.

Pain scales: VAS or numeric pain rating scale
Condition-specific function measures: ODI, NDI, WOMAC, SPADI, LEFS, FAAM
Document objective functional changes and date-stamped follow-up assessments

Documentation Required

Documentation Retention and Risk

Documentation retention: Providers must retain or have access to documentation supporting coverage, claims, and any prior authorization. Failure to provide required records on request may result in claim denial or noncoverage.

Retain complete medical record including history, exam findings (somatic dysfunction), treatment notes, and outcome measures
Be prepared to furnish documentation upon UnitedHealthcare or delegate request

Step Therapy

Stepwise Care Consideration — Exercise First

Step approach with exercise first: Conservative care pathways frequently recommend exercise therapy as first-line management for many musculoskeletal conditions. Manual therapies, including OMT, are often considered adjunctive to or combined with exercise, and prior authorization/coverage decisions may reflect a stepwise approach.

Document prior or concurrent conservative treatments such as prescribed exercise therapy and response to those therapies
When OMT is provided as part of a combined plan, document how OMT complements exercise and expected benefit

Prior Authorization

Follow Delegate Prior Authorization Rules

Delegate-managed prior authorization: For Medicare Advantage members whose utilization management is delegated, follow the delegate's prior authorization and utilization rules. Noncompliance with delegate requirements may affect claim payment and coverage.

Verify whether the member's plan uses a delegate for prior authorization
Follow the delegate's submission processes, documentation checklists, and timelines

Hands-on manual treatment of the spine (spinal manipulation/mobilization) evaluated in trials for acute and chronic low back pain.

Evidence summarySystematic reviews report small to moderate short-term improvements in pain and function for low back pain; effects vary by study and are of low-to-moderate quality.

Safety noteAssessment and reporting of harms were suboptimal in reviews but generally reported no serious harms; adverse events usually superficial or temporary increases in pain.

Typical outcomes assessedPain and function using tools such as VAS and numeric pain rating scales, with follow-up commonly at short-term (up to 6 weeks) and up to 3–6 months in some studies.

Osteopathic manipulative treatment (OMT) — definition/key points

DefinitionA set of manual therapy techniques performed by osteopathic physicians (examples: muscle energy, high velocity–low amplitude, counterstrain, myofascial release, visceral, craniosacral) applied to address somatic dysfunction.

Clinical roleUsed to facilitate recovery from somatic dysfunction and to improve physiologic function or support homeostasis altered by somatic dysfunction.

Technique selectionChosen techniques vary with patient age and clinical condition and may address skeletal, arthroidal, myofascial, vascular, lymphatic, or neural components.

Evidence contextEvaluated across conditions including pregnancy-related low back pain, neck, shoulder, hip and knee with mixed-quality evidence for short-term benefits.

Manual therapy / mobilization — definition/key points

DefinitionManual therapy and mobilization include joint mobilization, soft tissue techniques, muscle energy techniques, and related approaches often combined with exercise in trials.

Clinical applicationFrequently studied as an adjunct to exercise for shoulder conditions (eg, adhesive capsulitis, impingement) and other musculoskeletal disorders.

Evidence characteristicsRCTs and systematic reviews show short-term improvements in pain, ROM, and function in some conditions, but study heterogeneity and risk of bias limit certainty.

OMT (short definition)

Short definitionTherapeutic application of manually guided forces by an osteopathic physician to improve physiologic function or support homeostasis altered by somatic dysfunction.

Techniques includedExamples include muscle energy, HVLA, counterstrain, myofascial release, visceral, and craniosacral techniques.

Guideline supportAOA guideline (2016) recommends use of OMT for nonspecific acute and chronic low back pain based on systematic review evidence of reduced pain and improved function.

Somatic dysfunction (short definition)

Short definitionImpaired or altered function of components of the somatic system (skeletal, arthroidal, myofascial structures and related vascular, lymphatic, neural elements).

Diagnostic mnemonicIdentified by TART: tenderness, asymmetry, restriction of motion, tissue abnormality.

Clinical implicationSomatic dysfunction is considered treatable using OMT and may produce compensatory dysfunction in other regions.