Clinical Policy Title: Chiropractic care

Transcription

1 Clinical Policy Title: Chiropractic care Clinical Policy Number: Effective Date: December 1, 2013 Initial Review Date: July 17, 2013 Most Recent Review Date: July 3, 2018 Next Review Date: July 2019 Related policies: Policy contains: Chiropractic imaging. Chiropractic manipulation. Physical therapy in chiropractic practice. Spinal adjustment. None. ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas clinical policies are not guarantees of payment. Coverage policy AmeriHealth Caritas considers the use of chiropractic care services to be clinically proven and therefore, medically necessary when the following criteria are met: The care services are provided by a licensed chiropractor practicing within the scope of his/her license. The services are provided for neuromuscular symptoms amenable to chiropractic care for restoration of optimal function. There is a documented plan of care which directs chiropractic care to the presenting symptoms. Improvement is documented within three weeks after initiation of care, and there is a documented anticipated duration of chiropractic care with defined frequency of visits and end-point of treatment. There is no limit on chiropractic visits as long as medical necessity is documented. Chiropractic care is restricted to treatment of neuromuscular symptoms arising from the spine (Braddock, 2013). 0

2 Limitations: All other uses of chiropractic care services are not clinically proven, and therefore, investigational/ experimental. Alternative covered services: Physician office visits to primary care or orthopedic surgeon. Physical and/or occupational therapy services. Prescribed medications. Background Chiropractic is a body of knowledge, often regarded as an alternative/complementary health service, which holds that the relationship between the body s structure (primarily the spine) and function (primarily the nervous system) affects health. Spinal adjustment and manipulation are common chiropractic treatments, but numerous other services are considered chiropractic care (NCCIH, 2012). The 2007 National Health Interview Survey documented about eight percent of adults (more than 18 million) and nearly three percent of children (more than two million) had received chiropractic or osteopathic manipulation in the past 12 months, the most commonly-used alternative therapy in the U.S. Approximately one third of out of pocket costs for services rendered by complementary health practitioners were for visits to practitioners for chiropractic or osteopathic manipulation (Barnes, 2007). In the United Kingdom, a survey found that 7.5 percent of the population consulted a chiropractor in the 12 months prior, far greater than the figures of 1.9, 1.5, 1.4, and 0.9 percent for osteopaths, homeopaths, acupuncturists, and medical herbalists (Cooper, 2013). A recent literature review identified 337 articles; of these, 245 addressed chiropractic utilization patterns. A majority (57.0 percent) who consulted chiropractors were female, with a median age of 43.4 years. The most common reported reasons for people attending chiropractic care were (median) low back pain (49.7 percent), neck pain (22.5 percent), and extremity problems (10.0 percent). The most common treatment provided by chiropractors included (median) spinal manipulation (79.3 percent), soft-tissue therapy (35.1 percent), and formal patient education (31.3 percent) (Beliveau, 2017). Chiropractic care begins with a history and physical examination, and any needed tests, emphasizing the structure and function of the spine. Subsequent care often involves musculoskeletal adjustments to address patient needs. The desired outcomes of adjustments, which can be performed by using hands or devices, include an increase of range and quality of motion in the affected area. Other treatments used by chiropractors include heat/ice, electrical stimulation, relaxation, rehabilitative/general exercise, dietary supplements, and counseling about diet and weight. Like any health service, chiropractic care can result in adverse effects of treatment, including headache, fatigue, or discomfort with the body part that was treated. Serious complications can occur, but only rarely. 1

3 Chiropractic colleges are four-year academic programs after undergraduate education, and offer a Doctor of Chiropractic (D.C.) degree to its graduates. The four years are spent both in the classroom and in clinical patient care settings, and some chiropractors wishing to specialize pursue an additional 2 3 year residency program. To be licensed to practice, a chiropractor must pass an examination from the National Board of Chiropractic Examiners, and subsequently earn continuing credits. Each U.S. state has the power to regulate chiropractors (NCCIH), A number of professional guidelines govern recommended practices for chiropractors. Expert panels developed best practice consensus statements on the evaluation, management, and treatment of pediatric chiropractic patients (51 statements) (Hawk, 2009), and adult chiropractic patients (45 statements) (Hawk, 2017). A guideline from the Academy for Chiropractic Education that offers a helpful basic set of structural and process-oriented practices considered for the broad category of musculoskeletal injuries often addressed by chiropractors includes diagnosis and evaluation (medical history, physical examination, and diagnostic tests) and treatment and management (patient education, manual therapy, complementary procedures, active care and referrals) (Braddock, 2013). In 2009, the International Chiropractors Association issued a lengthy reference on best practices and best guidelines in chiropractic care, backed by results from hundreds of citations from the professional literature (Harrison, 2009). The Association followed this with a compendium of outcomes assessment measures in chiropractic, which again included hundreds of references from the professional literature (ICA, 2013). Searches We searched PubMed and the databases of: UK NHS Centre for Reviews and Dissemination. AHRQ guideline clearinghouse and evidence-based practice centers. Centers for Medicare & Medicaid Services (CMS). We conducted searches on May 4, 2018, using the terms chiropractic care, spine manipulation, chiropractic adverse effects, chiropractic back pain, and chiropractic services. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. 2

4 Findings Hundreds of meta-analyses and systematic reviews, and more randomized controlled trials, assessing effectiveness of chiropractic care exist in the medical literature. Some examples of these include various Cochrane reviews. Summaries of some of these reviews are given below; articles on chiropractic care for back pain are grouped first, with articles on chiropractic conditions following: BACK AND NECK PAIN 1. A review on treating acute lower back pain compared spinal manipulation to inert interventions, sham spinal manipulation (placebo), other interventions, and spinal manipulation as an additional therapy. In 20 trials (n=2674), outcomes from spinal manipulation were no better than any of the other groups (Rubenstein, 2012). The same comparison for chronic low back pain (26 RCTs, n=6070) found a small, statistically significant, but not clinically relevant shortterm effect on pain relief and functional status (Rubenstein, 2011). 2. A review of mechanical neck disorders, covering six trials with low risk of bias, found evidence to support use of cervical and scapular stretching and strengthening exercise for chronic neck pain immediately after treatment, and for cervicogenic headaches in the long term. Low to moderate evidence suggested no benefit for upper extremity stretching and strengthening exercises or general exercising (Kay, 2012). 3. A review of combined chiropractic interventions for low back pain, covering 12 studies and 2887 patients, found a slight improvement in pain and disability, but did not compare this approach with other therapies (Walker, 2010). 4. A review of 27 studies (n=1522) of patients with subacute and chronic neck pain found that cervical manipulation and mobilization produced similar improvements in pain compared to acupuncture, in the immediate or short term (Gross, 2010). An update found strengthening exercises for chronic neck pain, cervicogenic headache, and radiculopathy may be beneficial for chronic neck pain, and strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may also be beneficial, but strength of evidence was limited (Gross, 2015). 5. A review comparing massage one of the options in chiropractic care with various other treatment options for low-back pain included 25 studies (n=3096). Authors concluded that they had little confidence that massage is an effective treatment for lower back pain (Furlan, 2015). 6. A systematic review of six randomized controlled trials compared chiropractic care for low back pain treated with chiropractic care to exercise therapy, physical therapy, and medical care. Similar effects between the two groups were observed, with no reported serious adverse effects (Blanchette, 2016). 3

5 7. A systematic review of 25 articles compared chiropractic care and medical interventions for spine pain found similar outcomes for pain reduction (one was significantly better for chiropractic care). Physical functioning levels were significantly greater for chiropractic care at three and twelve months after initiation of therapy (Dagenais, 2015). 8. A meta-analysis of nine trials (n=1,176) compared mobilization and manipulation for low back pain with placebo or other treatments. Moderate evidence found manipulation was more effective in reducing pain and disability than exercise (p=.05) and physical therapy (p<.0001). Mobilization, compared with other active treatments, significantly reduced pain (p=.01) but fell short of significantly reducing disability (p=.07) (Coulter, 2018). OTHER CONDITIONS 9. A review of six studies (n=325) of infantile colic documented a reduction in hours of crying after manipulative therapies (Dobson, 2012). 10. A systematic review of six articles found that spinal manipulative therapy improved chronic obstructive pulmonary disease, both with and without exercise from a pulmonary rehabilitation program (Wearing, 2016). 11. Chiropractic adjustment resulted in a 24 percent (significant) reduction in nocturnal enuresis (bedwetting) in children compared to a sham adjustment, in 24 trials of 2334 children (Huang, 2011). Adverse effects from chiropractic manipulations and other treatments have historically suffered from poor reporting. A systematic review of 60 randomized controlled trials of manipulations found that 1) half did not mention adverse effects, and 2) complete reporting, i.e., incidence, severity, duration, frequency, and reporting method was present in just one (Ernest, 2012). Four years later, a systematic review reported that 38.0 percent of 368 articles on spinal manipulative therapy reported adverse events, which authors described as an improvement but still unacceptable (Gorrell, 2016). A systematic review documented 77 cases of spinal manipulative therapy to the lumbar spine or pelvis that resulted in a serious adverse event. The most common of these was cauda equine syndrome (38 percent), followed by lumbar disk herniation, fracture, hematoma or hemorrhagic cyst, or other serious adverse event (30, 9, 8, and 16 percent) (Hebert, 2015). Numerous other systematic reviews on chiropractic care have been published in the medical literature, covering topics such as hypertension, infant care, fibromyalgia, migraine headaches, gastrointestinal problems, asthma, and scoliosis. None of these conditions resulted in a recommendation of medical necessity, as the literature found either limited information, poor quality data, or no consistent evidence that chiropractic care was as or more effective than other treatments. 4

6 Policy updates: Four guidelines/other and 10 peer-reviewed references were added to this policy in A total of two guidelines/other and eight peer-reviewed references were added to, and two guidelines/other and three peer-reviewed references removed from, this policy in May, Summary of clinical evidence: Citation Gross (2015) Content, Methods, Recommendations Key points: Exercises for mechanical neck disorders Review of 27 trials (n=2485) with acute or chronic neck pain Cervico-scapulothoracic and upper extremity strength training improved pain short-term Scapulothoracic and upper extremity endurance training slightly improved pain short-term Combined cervical, shoulder, and scapulothorcic strengthening and stretching exercises varied from small to large magnitude of beneficial effect on pain Cervico-scapulothoracidc strengthening/stabilization exercises improved pain and function at intermediate term Mindfulness exercises minimally improved function short term Furlan (2015) Key points: Massage for low back pain Review of 25 trials (n=3096) of persons with low back pain (mostly chronic and sub-acute), massage mostly done with a mechanical device, as opposed to just hands Massage significantly better than inactive controls for pain and function, short term only Massage significantly better than active controls for pain (short + long term) but not function No reports of serious adverse effects Rubenstein (2012) Key points: Spinal manipulative therapy for acute low back pain Review of 20 randomized controlled trials (n=2674), adults only Spinal manipulative therapy (SMT) was found to have no difference in effect, compared to inert interventions, sham SMT, or when added to another intervention The decision to refer patients for SMT should be based on cost, patient preference, provider preference, and relative safety of SMT Rubenstein (2011) Key points: Spinal manipulative therapy for chronic low-back pain Review of 26 randomized controlled trials (n=6070); only 9 had low bias risk SMT has significant short-term effect on pain relief and functional status when added to another intervention, but quality of evidence ranges from low to high SMT is not significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status evidence is low quality. Walker (2010) Key points: Combined chiropractic interventions for low-back pain Review of 12 studies (n=2887); three studies had low risk of bias For acute and sub-acute lower back pain, chiropractic interventions improved short- and medium-term pain versus other treatments, but with no significant difference in long term pain Short-term disability improvement exceeded the chiropractic group compared to other therapies 5

7 References Professional society guidelines/other: Braddock EJ, Greenlee J, Hammer RE, et al. Manual medicine guidelines for musculoskeletal injuries. Sonora CA: Academy for Chiropractic Education, pp. nual_medicine_guidelines_for_musuloskeletal_injuries.pdf. Accessed May 4, Harrison DD, Siskin LA, eds. Best practices & practice guidelines. Arlington, VA: International Chiropractors Association (ICA); Accessed May 3, Hawk C, Schneider M, Ferrance RJ, Hewitt E, Van Loon M, Tanis L. Best practices recommendations for chiropractic care for infants, children, and adolescents: results of a consensus process. J Manipulative Physiol Ther. 2009;32(8): Hawk C, Schneider MJ, Haas M, et al. Best practices for chiropractic care for older adults: a systematic review and consensus update. J Manipulative Physiol Ther. 2017;40(4): International Chiropractors Association (ICA). Outcome Assessment Measures in Chiropractic. In: Best Practices and Practice Guidelines, pp Falls Church VA: ICA, Kent C, McCoy M, Rondberg T, Gutierrez V. Clinical Practice Guideline: Vertebral Subluxation in Chiropractic Practice. Council on Chiropractic Practice, pdf. National Center for Complementary and Integrative Health (NCCIH). Chiropractic: In Depth. Bethesda MD: NICCIH, Accessed May 4, Painter FM. Chiropractic Practice Guidelines. Canadian Memorial Chiropractic College (CMCC) and Anglo-European College of Chiropractic (AECOC). CMCC and AECOC, April 11, Peer-reviewed references: Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, Natl Health Stat Report. 2008;(12):

8 Beliveau PJH, Wong JJ, Sutton DA, et al. The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided. Chiropr Man Therap. 2017;25:35. Doi: /s Blanchette MA, Stochkendahl MJ, Borges Da Silva R, Boruff J, Harrison P, Bussieres A. Effectiveness and economic evaluation of chiropractic care for the treatment of low back pain: A systematic review of pragmatic studies. PLoS One. 2016;11(8):e Doi: /journal.pone Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: A randomized trial. Ann Intern Med. 2012;156(1 Part 1):1 10. Bronfort G, Haas M, Evena R, Leininqer B, Triano J. Effectiveness of manual therapies: The UK evidence report. Chiropr Osteopat. 2010;18:3. doi: / Bryans R, Descarreaux M, Duranleau M, et al. Evidence-based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther. 2011;34(5): Cooper KL, Harris PE, Relton C, Thomas KJ. Prevalence of visits to five types of complementary and alternative medicine practitioners by the general population: a systematic review. Complement Ther Clin Pract. 2013;19(4): Coulter ID, Crawford C, Hurwitz EL, et al. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J pii: S (18) doi: /j.spinee Dagenais S, Brady O, Haldeman S, Manga P. A systematic review comparing the costs of chiropractic care to other interventions for spine pain in the United States. BMC Health Serv Res. 2015;15:474. Doi: /s Dobson D, Lucassen PL, Miller JJ, Vlieger AM, Prescott P, Lewith G. Manipulative therapies for infantile colic. Cochrane Database Syst Rev. 2012:12:CD Ernst E, Posadzki P. Reporting of adverse effects in randomized clinical trials of chiropractic manipulations: a systematic review. N Z Med J. 2012;125(1353): Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015;(9):CD Gorrell LM, Engel RM, Brown B, Lystad RP. The reporting of adverse events following spinal manipulation in randomized clinical trials a systematic review. Spine J. 2016;(9): Gross A, Miller J, D Sylva J, et al. Manipulation or mobilization for neck pain. Cochrane Database Syst Rev. 2010;(1):CD

9 Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;1:CD Hebert JJ, Stomski NJ, French SD, Rubinstein SM. Serious adverse events and spinal manipulative therapy of the low back region: A systematic review of cases. J Manipulative Physiol Ther. 2013;38(20): Huang T, Shu X, Huang YS, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 2011;(12):CD Kay TM, Gross A, Goldsmith CH, et al. Exercises for mechanical disorders. Cochrane Database Syst Rev. 2012;(8):CD Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low-back pain. Cochrane Database Syst Rev Sep 12;9:CD Rubenstein SM, Middelkoop MV, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev. 2011(2):CD Walker BF, French SD, Grant W, Green S. Combined chiropractic interventions for low-back pain. Cochrane Database Syst Rev. 2010;(4):CD Wearing J, Beaumont S, Forbes D, Brown B, Engel R. The use of spinal manipulative therapy in the management of chronic obstructive pulmonary disease: A systematic review. J Altern Complement Med. 2016;22(2): CMS National Coverage Determinations (NCDs): No NCDs identified as of the writing of this policy. Local Coverage Determinations (LCDs): Chiropractic Services. L36617 FL, PR, VI; latest revision effective date 09/12/16. eyword=chiropractic&keywordlookup=title&keywordsearchtype=and&bc=gaaaacaaaaaaaa%3d% 3d&. Chiropractic Services. L33613 CT, IL, MA, ME, MN, NY, RI, VT; latest revision effective date 05/15/

10 KeyWord=chiropractic&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d %3d&. Chiropractic services. L34009 AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY; latest revision effective date 10/01/17. KeyWord=chiropractic&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&.. Chiropractic services. L34242 American Samoa, CA, Guam, HI, NV, Northern Mariana Islands; latest revision effective date 10/01/17. KeyWord=chiropractic&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&. Chiropractic services. L35424 AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX; latest revision effective date 10/01/17. KeyWord=chiropractic&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&. Chiropractic services. L34585 IA, IN, KS, MI, MO, NE; latest revision effective 02/01/18. KeyWord=chiropractic&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&. Chiropractic services. L37254 KY, OH; latest revision effective 01/16/18. eyword=chiropractic&keywordlookup=title&keywordsearchtype=and&bc=gaaaacaaaaaa&. Chiropractic services. L37387, AL, GA, NC, SC, TN, VA, WV; latest version effective 02/26/18. eyword=chiropractic&keywordlookup=title&keywordsearchtype=and&bc=gaaaacaaaaaa&. NOTE: Durable medical equipment ordered by a chiropractic physician is not covered. Commonly submitted codes 9

11 Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comments Chiropractic manipulative treatment, Spinal 1-2 regions Chiropractic manipulative treatment, Spinal 3-4 regions Chiropractic manipulative treatment, Spinal 5 regions Chiropractic manipulative treatment, Extraspinal 1 or more regions ICD-10 Code Description Comments 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 M00.09 Segmental and somatic dysfunction of abdomen or other regions HCPCS Level II Code N/A Description N/A Comments 10