CurrentuniverahealthcarePolicy 10.01.02

Chiropractic Care

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This policy governs coverage and medical necessity criteria for chiropractic care provided by a licensed Doctor of Chiropractic (DC) for neuromusculoskeletal conditions. It applies to Univera Healthcare benefit determinations for members receiving chiropractic services.

Policy Summary

Payeruniverahealthcare

PolicyChiropractic Care

Policy CodePolicy 10.01.02

Change TypeAnnual review — no material changes

Effective DateJul 16, 2026

Last ReviewJul 16, 2026

Next Review DateJul 1, 2027

Key ActionDocument history, exam, diagnosis, expected functional improvement and individualized treatment plans when providing chiropractic care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

maintenanceMaintenance care excluded

S8990HCPCS S8990 NMN

reviewRetrospective review

x‑rayX‑ray restrictions

~13

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CurrentuniverahealthcarePolicy 10.01.02

Chiropractic Care

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Policy Summary

Payeruniverahealthcare

PolicyChiropractic Care

Policy CodePolicy 10.01.02

Change TypeAnnual review — no material changes

Effective DateJul 16, 2026

Last ReviewJul 16, 2026

Next Review DateJul 1, 2027

Key ActionDocument history, exam, diagnosis, expected functional improvement and individualized treatment plans when providing chiropractic care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

maintenanceMaintenance care excluded

S8990HCPCS S8990 NMN

reviewRetrospective review

x‑rayX‑ray restrictions

~13

98940-98943CPT codes listed

Coverage and Medical Necessity Criteria

Medically appropriate chiropractic care

Chiropractic care is considered medically appropriate when ALL of the following are met:

Eligibility criteria: There is documented history, examination, and diagnosis of a neuromusculoskeletal condition; there is a reasonable expectation of recovery or improvement in function; treatment is provided in accordance with standards of generally accepted chiropractic practice; the diagnostic procedures and therapeutic interventions are clearly related to the patient's symptoms/condition being treated; individualized treatment plans incorporate objective measures of patient-based outcomes.

All elements must be present

Red Flag Criteria

Examples of red flags — consider further diagnostic evaluation or alternate management when ANY of the following are present:

Red flags list: Unexplained weight loss; immunosuppression; urinary infection; intravenous drug use; prolonged use of corticosteroids; back pain not improved with conservative management; history of significant trauma; minor fall or heavy lift in a potentially osteoporotic or elderly individual; acute onset of urinary retention or overflow incontinence; loss of anal sphincter tone or fecal incontinence; saddle anesthesia; global or progressive motor weakness in the lower limbs.

Presence of any of these may indicate more serious underlying condition requiring further workup or referral.

Coverage statements

Policy stance and conditional coverage statements found in this section:

General Coverage Conditions: Coverage is product-dependent; medical policy criteria apply when a commercial product covers the service and when Medicaid/Medicare products lack specific external guidelines.

See product-specific benefit details and prior authorization rules.

Maintenance Therapy: Services described by HCPCS S8990 (maintenance therapy) are designated Not Medically Necessary.

Claims for maintenance rather than restoration may be denied.

Coding Requirements: Chiropractic manipulation should be reported using CPT 98940–98943 with appropriate region counts; modifier AT may be used to indicate acute or active treatment for 98940–98942.

Follow AMA/CMS coding guidance; codes may not be covered under all circumstances.

Chiropractic care is considered not medically necessary as a treatment intervention to restore spinal curves or for the treatment of idiopathic scoliosis in an asymptomatic patient.

Chiropractic care is designated investigational when rendered for non‑neuromusculoskeletal conditions. Examples include, but are not limited to, infantile colic, childhood asthma, hypertension, and primary dysmenorrhea — uses for which adequate, high‑quality evidence of benefit has not been established.

Supportive literature is limited regarding chiropractic or manual therapies for altering the natural history of scoliosis. Systematic reviews and evidence summaries have not established efficacy for correcting scoliotic curve progression; manual therapies may improve joint mobility or relieve pain associated with scoliosis but have not been shown to change curve progression. Similarly, systematic reviews of spinal manipulative therapy for non‑musculoskeletal disorders did not demonstrate superiority to sham interventions.

HCPCS code S8990 is described as “Physical or manipulative therapy performed for maintenance rather than restoration” and is designated Not Medically Necessary (NMN) when billed as maintenance therapy.

Maintenance care is defined as care that begins after therapeutic goals have been achieved or when no additional functional progress is apparent or expected. Such maintenance care is considered not medically necessary, and services performed for maintenance rather than restoration (for example those described by HCPCS S8990) may be denied.

Routine or repeat plain film spinal radiographs to assess spine function or structure are considered not medically necessary in the absence of clinical red flags or other indications of serious underlying pathology. Radiographic re‑examination decisions should be based on patient symptoms, physical findings, and the potential impact of imaging results on the treatment plan.

The evidence does not support use of spinal manipulative therapy for non‑musculoskeletal disorders. A systematic review of randomized controlled trials found spinal manipulative therapy was not superior to sham interventions for non‑musculoskeletal conditions, and long‑term randomized controlled trial evidence demonstrating benefit is lacking for conditions such as hypertension, asthma, and infantile colic.

The HCPCS code S8990 specifically delineates therapy performed for maintenance rather than restoration. When services are provided for maintenance purposes as defined by the policy, the code is designated NMN and claims may be denied for lack of medical necessity.

Coding and Billing

General code annotationsmixed

No codes listed

Covered CPT Codes (listed)CPT

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

HCPCS (Not Medically Necessary)HCPCSNot Covered

S8990

Physical or manipulative therapy performed for maintenance rather than restoration

ICD-10 CodesICD-10

Multiple

ICD-10 codes referenced; specific codes not listed in this section

Provider Requirements, Documentation, and Billing Guidance

Prior Authorization

Scope: Services must be provided by a licensed DC within scope of practice

Coverage of chiropractic care is limited to medically necessary services provided by a licensed Doctor of Chiropractic (DC) within the scope of their license, in connection with detection or correction of spinal misalignment or mechanical/myofascial extremity pain.

Note

NY regulatory requirement: chiropractic coverage under specified contracts

New York State law requires contracts that provide physician or similar comprehensive-type coverage to include coverage for chiropractic care as defined in state statute; providers in NY should follow applicable regulatory definitions and coding/policy guidance.

Prior Authorization

Verify benefits and prior authorization — services are contract dependent

Background and Evidence Summary

Chiropractic care is an intervention for neuromusculoskeletal conditions provided by licensed Doctors of Chiropractic. Coverage is limited to medically necessary services provided by a licensed DC within the scope of their license and is evaluated based on documented history, examination, diagnosis of a neuromusculoskeletal condition, a reasonable expectation of recovery or functional improvement, and treatment that is clearly related to the patient’s symptoms and incorporates objective patient‑based outcome measures.

Definitions

Maintenance care definition

DefinitionCare that begins when the therapeutic goals of a treatment plan have been achieved or when no additional functional progress is apparent or expected to occur.

Coverage stanceMaintenance care is considered not medically necessary.

ImplicationClaims for care billed as maintenance (i.e., after goals met or no further functional progress expected) may be denied on retrospective review.

Covered chiropractic scope

Provider requirementServices must be provided by a licensed Doctor of Chiropractic (DC) within the scope of their license.

Scope of servicesCare related to detection or correction of spinal misalignment or mechanical/myofascial extremity pain.

Policy History

2026-07-16review/approvalLatest

Annual review completed; policy intent unchanged (most recent review/approval).

2025-07-17review/approval

Annual review completed; policy intent unchanged.

2025-01-01administrative update

Policy Summary

Payeruniverahealthcare

PolicyChiropractic Care

Policy CodePolicy 10.01.02

Change TypeAnnual review — no material changes

Effective DateJul 16, 2026

Last ReviewJul 16, 2026

Next Review DateJul 1, 2027

Key ActionDocument history, exam, diagnosis, expected functional improvement and individualized treatment plans when providing chiropractic care.

SourceLink

On This Page

Benefit coverage and any prior authorization requirements are product dependent; if a product does not cover a service, medical policy criteria do not apply. Verify the member's product benefit and prior authorization rules before delivering services.

Step Therapy

Step therapy: none specified

No step therapy requirements are specified in this portion of the document.

Note

Expect conservative care before escalation

Conservative management is expected before escalation; back pain not improved with conservative management is listed among red-flag contexts where further evaluation or alternate management may be warranted.

Step Therapy

Step therapy (duplicate): not specified

No additional step therapy requirements are specified in this section.

Documentation Required

Required clinical documentation: history, exam, diagnosis, recovery expectation, outcome measures

Document a complete history, focused physical examination, and the diagnosis of a neuromusculoskeletal condition; include a reasonable expectation of recovery or functional improvement and individualized treatment plans incorporating objective patient-based outcome measures.

Documentation Required

Document contraindications: confirm absence of listed contraindications

Before providing chiropractic interventions, document the absence of listed contraindications (examples include recent compression fracture, severe osteoporosis, active inflammatory arthropathy, infection, cauda equina syndrome, progressive or sudden neurological deficit, and visceral disease).

Documentation Required

Documentation required when ordering imaging: clinical findings and rationale

When ordering plain radiographs, document the clinical findings, symptoms, and the specific rationale for imaging; decisions for radiographic re-examination should be based on patient symptoms, physical findings, and the potential impact of results on the treatment plan.

Avoid routine screening radiographs without clinical indications.
Re-examination imaging must be tied to changes in symptoms or findings that would alter management.

Billing Rule

Coding and modifier use: CPT 98940–98942 and modifier AT

Report chiropractic manipulative treatment using CPT codes 98940–98942 according to region counts; use modifier AT to indicate acute or active treatment when reporting 98940–98942 as applicable. Codes may not be covered under all circumstances — confirm product coverage.

CPT 98940 = spinal, 1–2 regions; 98941 = spinal, 3–4 regions; 98942 = spinal, 5 regions.
Use modifier AT for acute/active treatment when appropriate.

Denial Risk

Denial risk: retrospective utilization review may deny non‑medically necessary services

All chiropractic services are subject to retrospective utilization review; services determined on retrospective review to be not medically necessary will be denied.

Denial Risk

Maintenance care exclusion: maintenance considered not medically necessary

Maintenance care — care begun after therapeutic goals are achieved or when no additional functional progress is expected — is considered not medically necessary and may be denied.

Denial Risk

Routine/repeat x‑ray denial risk: repeat imaging without red flags may be denied

Routine or repeat spinal x-rays without red flags or clinical suspicion of serious pathology are considered not medically necessary and may be denied; avoid repeat imaging when no red flags or new clinical indications exist.

Plain film radiographs should not be used as a screening procedure without clinical indications.
Repeat imaging decisions should be based on symptoms or findings that would change management.

Note

Imaging without red flags or clinical indication: routine spinal x‑rays discouraged

Routine spinal x‑rays without clinical indications are discouraged; use plain film radiographs only when clinical findings suggest serious pathology or when results would affect treatment decisions.

Note

Coverage conditionality: codes may not be covered in all circumstances

Coverage and coding may be conditional; codes listed in the policy may not be covered under all circumstances — verify coverage for the specific product and clinical situation.

Denial Risk

Maintenance therapy not covered: HCPCS S8990 designated NMN

HCPCS S8990 (physical or manipulative therapy performed for maintenance rather than restoration) is designated Not Medically Necessary (NMN); claims billed as maintenance rather than restoration may be denied.

Do not bill S8990 for restorative care intended to meet therapeutic goals; S8990 is NMN when used to indicate maintenance.

Clinical contextDCs evaluate, diagnose, and treat neuromusculoskeletal complaints (e.g., back pain, neck pain, joint pain, headaches) using hands-on, drug-free approaches.

Spinal manipulation (SMT)

DefinitionManual application of a controlled force into hypomobile (restricted) joints to restore joint mobility.

PurposeRestores mobility, potentially alleviating pain, reducing muscle tightness, and restoring function.

SynonymOften referred to as a chiropractic adjustment or manipulation.

Red flags (examples)

Examples (compact)Unexplained weight loss; immunosuppression; urinary infection; intravenous drug use; prolonged corticosteroid use; back pain not improved with conservative management; history of significant trauma; minor fall or heavy lift in potentially osteoporotic/elderly individuals; acute onset urinary retention/overflow incontinence; loss of anal sphincter tone or fecal incontinence; saddle anesthesia; progressive lower‑limb motor weakness.

ActionPresence of any red flag should prompt further diagnostic evaluation or alternate management/referral.

Clinical settingApplies to back pain and/or back pain with radiculopathy scenarios.

Chiropractic Manipulative Treatment (CMT) — CPT 98940–98942

98940Chiropractic manipulative treatment (CMT); spinal, 1-2 regions.

98941Chiropractic manipulative treatment (CMT); spinal, 3-4 regions.

98942Chiropractic manipulative treatment (CMT); spinal, 5 regions.

98943Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions.

Maintenance therapy (HCPCS S8990) — definition

HCPCS S8990 descriptionPhysical or manipulative therapy performed for maintenance rather than restoration.

Policy designationS8990 is designated Not Medically Necessary when billed as maintenance therapy.

Coverage implicationClaims for services described by S8990 billed as maintenance rather than for restoration may be denied.

Summary-of-changes tracking implemented.

2001-10-18policy creation/approval

Original effective date / initial committee approval.