CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy 4.220

Chiropractic Services

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Coverage, provider qualifications, medical necessity, prior authorization, documentation, and non-covered services for chiropractic care under Vermont Medicaid.

Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyChiropractic Services

Policy CodePolicy 4.220

Change TypeNo material change

Effective DateFeb 20, 2025

Next Review DateN/A

Key ActionObtain prior authorization and primary-care medical-necessity documentation for chiropractic services provided to children age five and under.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Manual manipulationCovered service

Under 12Prior authorization

Age 5 and underPA plus documentation

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CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy 4.220

Chiropractic Services

Customize your policy alerts

Sign up for Vermont Agency of Human Services – Department of Vermont Health Access Policy 4.220 alerts

Get alerted when Policy 4.220 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage, provider qualifications, medical necessity, prior authorization, documentation, and non-covered services for chiropractic care under Vermont Medicaid.

Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyChiropractic Services

Policy CodePolicy 4.220

Change TypeNo material change

Effective DateFeb 20, 2025

Next Review DateN/A

Key ActionObtain prior authorization and primary-care medical-necessity documentation for chiropractic services provided to children age five and under.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Manual manipulationCovered service

Under 12Prior authorization

Age 5 and underPA plus documentation

3 monthsImaging lookback

Adjunctive therapyNot covered

Covered Chiropractic Services

Covered chiropractic services

Covered when all of the following are met:

Covered chiropractic service: The service is manual manipulation of the spine to correct a spinal subluxation.

Qualified provider: The service is provided by a licensed chiropractor working within the scope of practice and enrolled in Vermont Medicaid.

Medical necessity: The service is medically necessary according to Health Care Administrative Rule 4.101, Medical Necessity for Covered Services.

Demonstration of subluxation

Diagnostic imaging route: The subluxation is demonstrated by diagnostic imaging ordered by a medical provider other than a chiropractor no earlier than three months before initiation of care.No earlier than 3 months prior to initiation of care
Physical examination route: The subluxation is demonstrated by a physical examination conducted by the chiropractor performing the correction.

Medical imaging ordered solely to demonstrate a subluxation of the spine is not covered. Any charges for chiropractic imaging used solely for this purpose may be billed to the beneficiary only when written notice is provided before the procedure.

Adjunctive therapies performed by chiropractors are not covered.

Authorization, Documentation, and Denial Risks

Prior Authorization

Children Under 12

Prior authorization is required for chiropractic services provided to beneficiaries under age 12, except for children ages 6–11 when services are provided by a pediatric chiropractic provider with identified credentials.

The exception applies to providers with a Doctor of Chiropractic (DC) credential and certification by the Academy Council of Chiropractic Pediatrics (ACCP).

Prior Authorization

Services Beyond Annual Limits

Obtain prior authorization for beneficiaries age 12 and older when requested chiropractic services exceed the published annual limits.

Verify the current annual limits on the Department of Vermont Health Access website before providing services beyond the limit.

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Policy Scope

Chiropractic services are treatment by manual manipulation of the spine in accordance with 42 CFR § 440.60(b). Covered chiropractic care is limited to manual manipulation of the spine to correct a demonstrated spinal subluxation—a vertebra that is out of position compared with the other vertebrae. The subluxation must be supported by qualifying diagnostic imaging or by a physical examination conducted by the chiropractor performing the correction.

Key Terms

Definitions

Chiropractic servicesTreatment by means of manual manipulation of the spine in accordance with 42 CFR § 440.60(b).

Definitions

SubluxationA spinal vertebra that is out of position in comparison to the other vertebrae.

Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyChiropractic Services

Policy CodePolicy 4.220

Change TypeNo material change

Effective DateFeb 20, 2025

Next Review DateN/A

Key ActionObtain prior authorization and primary-care medical-necessity documentation for chiropractic services provided to children age five and under.

SourceLink

On This Page

Prior Authorization

Services Beyond Annual Limits

For beneficiaries age 12 and older, prior authorization is required when services exceed the published annual limits.

Check the Department of Vermont Health Access website for the applicable annual limits before rendering additional services.

Prior Authorization

Children Age Five and Under

Services for children age five and under require prior authorization and documentation of medical necessity from a Medicaid-enrolled primary care provider working within the provider’s scope of practice.

Include the required primary-care-provider medical-necessity documentation with the authorization request.

Documentation Required

Document the Subluxation

Demonstrate the existence of a spinal subluxation through one of the policy-approved pathways before seeking coverage for correction.

Diagnostic imaging must be ordered by a medical provider other than a chiropractor and performed no earlier than three months before initiation of care.
Alternatively, the chiropractor performing the correction may establish the subluxation through a physical examination.

Unsupported block type: documentation

Denial Risk

Notice Before Non-Covered Imaging

Medical imaging ordered solely to demonstrate a spinal subluxation is not covered. Before performing that imaging, provide written notice to the beneficiary if charges may be billed to the beneficiary.

Written notice must be given before the procedure is performed.

Denial Risk

Scope of Covered Services

Covered chiropractic services are limited to manual manipulation of the spine to correct a demonstrated spinal subluxation. Services outside manual spinal manipulation, or services without a demonstrated subluxation, are not covered.

Do not submit services that are not manual manipulation of the spine.
Retain documentation supporting the existence of the subluxation through an approved pathway.

Denial Risk

Qualified Provider Required

Chiropractic services must be furnished by a licensed chiropractor who is working within the scope of practice and enrolled in Vermont Medicaid.

Failure to meet licensure, scope-of-practice, or Vermont Medicaid enrollment requirements creates a denial risk.

Denial Risk

Medical Necessity Required

All chiropractic services must be medically necessary under Health Care Administrative Rule 4.101, Medical Necessity for Covered Services.

Document and apply the Rule 4.101 medical-necessity standard to every chiropractic service.

Denial Risk

Non-Covered Imaging and Adjunctive Therapy

Medicaid does not cover imaging ordered solely to demonstrate a spinal subluxation, and adjunctive therapies performed by chiropractors are not covered.

Do not bill Medicaid for imaging ordered solely to demonstrate subluxation.
Adjunctive therapies performed by chiropractors are non-covered services.
Charges for qualifying chiropractic imaging may be billed to the beneficiary only after written notice is provided before the procedure.