EMPIRE MEDICARE SERVICES NEW YORK STATE MEDICARE LOCAL MEDICAL REVIEW POLICY

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1 EMPIRE MEDICARE SERVICES NEW YORK STATE MEDICARE LOCAL MEDICAL REVIEW POLICY CPT codes, descriptions, and other data only are copyright 2000 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply. Contractor Policy Number:CH001E00 Contractor Name: Empire Medicare Services Contractor Number: Contractor Type: Carrier LMRP Title: Chiropractic Services AMA CPT Copyright Statement: CPT codes, descriptions, and other data only are copyright 2000 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. CMS National Coverage Policy:! Title XVIII of the Social Security Act, section 1862(a)(7) This section excludes routine physical examinations.! Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered reasonable and necessary.! Title XVIII of the Social Security Act, section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.! Medicare Carriers Manual (CAR 3) Section This section addresses general chiropractic services.! Medicare Carriers Manual (CAR 3) Section This section addresses coverage of chiropractic services.! Medicare Carriers Manual (CAR 3) Section This section addresses chiropractic services and documentation requirements. Primary Geographic Jurisdiction: Downstate New York, excluding Queens CMS Region: 02 CMS Consortium: Northeast Policy Effective Date: January 29, 2001 Revision Effective Date: Revision Ending Effective Date: Policy Ending Date: LMRP Description: Chiropractic service is eligible for reimbursement but is specifically limited by Medicare to treatment by means of manual manipulation (i.e., by use of the hands) of the spine for the purpose of correcting a subluxation. For the purpose of Medicare, subluxation is defined as an intervertebral motion segment in which alignment movement integrity and/or physiological function of the spine are altered although contact between intervertebral joint surfaces remains intact, and usually falls into one of three categories:! Acute subluxation: A patient s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified in the Docum entation Requirements section of the policy. The result of chiropractic manipulation is expected to be an improvement in, arrest or retardation of the patient' s condition.! Chronic subluxation: A patient s condition is considered chronic when it is not expected to

2 completely resolve (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is not covered.! Nerve root problems, such as a pinched nerve, when they are the result of acute or chronic subluxations as described above. The therapeutic force or maneuver delivered by the practitioner during manipulation in the anatomic region of involvem ent is known as dynam ic thrust. No other diagnostic or therapeutic service furnished by a chiropractor or under his/her order is covered under the Medicare program. Acceptable terminology for the manipulative treatment being provided includes:! Spine or spinal adjustment by manual means! Spine or spinal manipulation! Manual adjustment; and! Vertebral manipulation or adjustment Indications and Limitations of Coverage and/or Medical Necessity: Indications:! The patient must have a subluxation of the spine, as defined in the Description section of the policy.! A patient must have a significant health problem in the form of a neuro-musculoskeletal condition related to a subluxation necessitating treatments. The manual manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function.! Spinal axis aches, strains, sprains, nerve pains and functional mechanical disabilities of the spine are considered to be medically necessary therapeutic grounds for chiropractic manipulative treatm ent.! The following are some examples of acceptable descriptive terms for the nature of the abnormalities: Off-centered Misalignment Malpositioning Spacing o abnormal o altered o decreased o increased Incomplete dislocation Rotation Listhesis o antero o postero o retro o latereol o spondylo Motion o limited o lost o restricted o flexion o extension o hyper mobility

3 o hypomotility o aberrant! There are four categories of conditions that Medicare covers: 1. Acute A patient's condition is considered to be acute when the patient is being treated for a new injury that is substantiated by x-ray (or an existing MRI, or CT scan) or physical exam. Limitations: 2. Exacerbation An exacerbation is a temporary, marked deterioration of the patient's condition due to an acute flare-up of the condition being treated. This must be documented in the patient's clinical record, including the date of occurrence, nature of the onset, or other pertinent factors that will support the medical necessity of treatments for this condition. 3. Recurrence A recurrence is a return of symptoms of a previously treated condition that has been quiescent for 30 or m ore days. This may require the reinstitution of therapy. 4. Chronic A patient's condition is considered chronic when it is not expected to completely resolve (as would an acute condition), but where continued therapy can be expected to result in some functional improvement.! Once the functional status has rem ained stable for a given condition, further manipulative treatment is considered maintenance therapy and is not covered. Maintenance therapy (e.g., a treatment plan that seeks to prevent disease, promote health, prolong and enhance the quality of life, or therapy that is performed beyond the stabilization of a chronic condition) is not a Medicare benefit.! Chiropractic manipulative treatment is an excluded service under Medicare for most spinal diseases and pathologies other than those listed in the Indications section. Exam ples of these (not an all inclusive list) are rheumatoid arthritis, muscular dystrophy, multiple sclerosis, pneumonia, and emphysema.! The mere statement or diagnosis of "pain" is not sufficient to support medical necessity for the treatments.! The need for an extensive, prolonged course of treatment must be clearly documented in the medical record. Treatment should result in improvement or arrest of deterioration of subluxation within a reasonable and generally predictable period of time. Acute subluxation problems (e.g., strains or sprains) may require as many as three months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but may decrease in frequency with time or as improvement is obtained.! Coverage will be denied for lack of reasonable expectation that the continuation of treatm ent would result in significant improvement of the patient's condition. Continued repetitive treatment without an achievable and clearly defined goal is considered maintenance therapy and is not covered.! Manual devices (those devices that are hand-held with the thrust of the force of the device being controlled manually) may be used by the chiropractor in performing manual manipulation of the spine. However, no additional payment is allowed for the use of the device or for the device itself.! Only a single manipulation service (98940, 98941, or 98942) may be billed on any one date of service by the same or different providers.! Manual spinal manipulations may be performed in the office (11), home (12), inpatient hospital (21),

4 outpatient hospital (22), emergency room (23), nursing facility (31,32), custodial care facility (33), comprehensive outpatient rehabilitation facility (62), or state or local public health clinic (71). Contraindications to Dynamic Thrust:! The following are relative contraindications to dynamic thrust. A relative contraindication is that condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The chiropractor should discuss this risk with the patient and record this in the chart. 1. Articular hypermobility and circum stances where the stability of the joint is uncertain 2. Severe demineralization of bone 3. Benign bone tumors (spine) 4. Bleeding disorders and anticoagulant therapy 5. Radiculopathy with progressive neurological signs! Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following: 1. Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation, including acute rheum atoid arthritis and ankylosing spondylitis 2. Acute fractures and dislocations, or healed fractures and dislocations with signs of instability 3. An unstable os odontoideum 4. Malignancies that involve the vertebral column 5. Infection of the bones or joints of the vertebral column 6. Signs and symptoms of myelopathy or cauda equina syndrome 7. For cervical spinal manipulations, vertebrobasilar insufficiency syndrome 8. A significant major artery aneurysm near the proposed manipulation Program Exclusions: Treatment of certain conditions may be excluded from coverage if it falls outside the scope of a chiropractor's practice as defined by New York State Law.! Some chiropractors have been identified as using an "intensive care" concept of treatm ent. Under this approach, multiple daily visits (as many as four or five in a single day) are given in the office or clinic and so-called room or ward fees are charged, since the patient is confined to bed usually for the day. The room or ward fees are not covered and reimbursement under Medicare will be limited to not more than one treatment per day unless documentation of the reasonableness and necessity for additional treatm ent is submitted with the claim. CPT/HCPCS Section & Benefit Category: Medicine/Chiropractic CPT/HCPCS Codes: Chiropractic manipulative treatment (CMT); spinal, one to two regions ; spinal, three to four regions ; spinal, five regions *98943 ; extraspinal, one or more regions A9170 Non-covered service, by chiropractor *National policy (Section 2251) limits the coverage of chiropractic services to the "hands on" manual manipulation of the spine for symptomatology associated with spinal subluxation. Accordingly, CPT code 98943, CMT, extraspinal, one or more regions, is not a Medicare benefit. ICD-9-CM Codes That Support Medical Necessity:

5 TRUNCATED DIAGNOSIS CODES ARE NOT ACCEPTABLE. ICD-9-CM code listings may cover a range and include truncated codes. It is the provider's responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the claim is submitted. It is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis or clinical suspicion must be present for the procedure to be paid. The following primary and secondary ICD-9-CM diagnoses represent the specific clinical indications to support the need for chiropractic manipulation. Both a primary and secondary diagnosis must be listed on each claim. Primary Diagnosis Codes: Name of Vertebrae Occipitocervical (Occ-C1) Nonallopathic lesions Cervical (C1-C7) Nonallopathic lesions C1 (Atlas) Nonallopathic lesions C2 (Axis) Nonallopathic lesions Dorsal (D1-D12) or Nonallopathic lesions Thoracic (T1-T2) Nonallopathic lesions Lumbar (L1-L5) Nonallopathic lesions Sacrococcygeal (S) Nonallopathic lesions Pelvic region Nonallopathic lesions Costobertebral, costotransverse (R1-R12) Secondary ICD-9-CM codes: Category I: Diagnoses that generally require short term treatment Tension headache Cervical spondylosis without myelopathy Thoracic and lumbosacral spondylosis without myelopathy Cervicalgia Pain in thoracic spine Lumbago Backache, unspecified Headache Category II: Diagnoses that generally require moderate term treatment Nerve root and plexus disorders Other nerve root and plexus disorders Spinal enthesopathy Other and unspecified disc disorder Spinal stenosis in cervical region Cervicocranial syndrome

6 723.3 Cervocobrachial syndrome (diffuse) Brachial neuritis or radiculitis, NOS Torticollis, unspecified Spinal stenosis, thoracic region Spinal stenosis, lumbar region Thoracic or lumbosacral neuritis or radiculitis, unspecified Disorders of sacrum, ankylosis Other disorders of coccyx, coccygodynia Other symptoms referable to back, facet syndrome Pain in limb Acquired spondylolisthesis Spondylolisthesis Sprains and strains of lumbosacral (joint) (ligament), sacroiliac (ligament), sacrospinatus (ligament), sacrotuberous (ligam ent) Sprains and strains of other specified sites of sacroiliac region Sprains and strains of specified parts of the back Category III: Diagnoses that may require longer term treatment Traumatic spondylopathy Displacement of cervical intervertebral disc without myelopathy Displacement of lumbar or thoracic intervertebral disc without myelopathy Degeneration of cervical intervertebral disc Degeneration of thoracic or lumbar intervertebral disc Postlaminectomy syndrome Sciatica ICD-9-CM Codes that DO NOT Support Medical Necessity: N/A Reasons for Denial:! Claims submitted without a valid ICD-9-CM diagnosis code will be returned as incomplete claim under 1833 (e)! Claims submitted without an ICD-9-CM diagnosis code listed as covered will be denied under 1862 (a)(1)(a).! Claims for services rendered in any place of service other than those listed as covered in the Limitations section will be denied.! Claims submitted without both a primary and secondary diagnosis will be denied for medical necessity.! Services which constitute m aintenance therapy will be denied as not m edically necessary.! Claims for the use of a manual device or for the device itself will be denied.! Excluded Services:! No other diagnostic or therapeutic service furnished by a chiropractor or under his or her order is covered. This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test can be used for claims processing purposes, but Medicare coverage and paym ent are not available for those services. The following are exam ples (not an all inclusive list) of services that, when performed or ordered by the chiropractor, are excluded from

7 Medicare coverage and for which the beneficiary is responsible for payment:! Therapy for a chronic condition that does not meet the definition as described in the "Indications and Limitations" section of this policy o Maintenance therapy o Laboratory tests o X-rays/MRI/CT Scans o Evaluation and management services o Physiotherapy o Traction o Supplies o Injections o Drugs o EKGs or any diagnostic study o Acupuncture o Orthopedic devices o Nutritional supplements/counseling o Any service ordered by the chiropractor o Any manipulation where there exists one of the absolute contraindications o Mechanical or electric equipment that is used for manipulations and does not meet the definition of "manual device" as specified in the "Description" section of this policy o Any manipulation where the x-ray (or existing MRI or CT scan) or examination does not support one of the primary diagnoses listed in the "ICD-9-CM Diagnoses That Support Medical Necessity" section of this policy.! Coverage will be denied for lack of reasonable expectation that the continuation of treatm ent would result in functional long-term improvement of the patient's condition. Continued, repetitive treatment without an achievable and clearly defined goal is considered maintenance therapy and is not covered.! Code will be denied as it is not a covered Medicare benefit. Non-covered ICD-9-CM Code(s):! Any ICD-9-CM diagnosis code that has not been listed in this policy as a primary or secondary diagnosis will be denied. If the claim does not have one of the primary diagnoses, the claim will be denied as not m edically necessary.! Use of ICD-9-CM diagnosis code V82.9 (Special screening of other conditions, unspecified condition) will result in the denial of claims as non-covered screening services. Coding Guidelines: 1. A total of two diagnoses are required on every claim. The precise level of the subluxation must be listed as the primary diagnosis, while the resulting disorders are to be listed as the secondary diagnosis. 2. All ICD-9-CM diagnosis codes must be coded to the highest level of specificity (4th or 5th digit). 3. The date of the initial treatment or date of exacerbation of the existing condition m ust be entered in box 14 of the CMS-1500 form or the electronic equivalent. 4. For dates of service prior to January 1, 2000, the date of the x-ray (or existing MRI or CT scan) must be entered in Box 19 of the CMS-1500 form or the electronic equivalent. 5. Diagnostic x-rays, evaluation and management services and physical therapy are not covered when performed by chiropractors. For the purposes of secondary coverage, these services may be coded so that proper denials will be shown on the Explanation of Medicare Benefits form. 6. A radiologist (or another authorized ordering practitioner) may accept a referral for an x-ray by doctors of chiropractic. The chiropractor may not order the x-ray. 7. If an authorized ordering practitioner orders the x-ray, then he/she should enter his/her name in box 17 of the CMS-1500 form and his/her UPIN number in box 17a of the CMS-1500 form, or the electronic equivalent, as the ordering physician. 8. Chiropractic services may be reported for office (11), home (12), inpatient hospital (21), outpatient hospital (22), emergency room (23), skilled nursing facility (31), nursing home (32), custodial care

8 facility (33), com prehensive outpatient rehabilitation facility (62), or state or local public health clinic (71). 9. For services performed from January 1, 1999 through December 31, 1999, the chiropractor must code the claim with one of the CPT codes for chiropractic manipulation and modifier GX (Service not covered by Medicare) when the patient refuses to have an x-ray. The claims will be denied as technical denials. Note: For claims prior to January 1, 1999, use HCPCS code A9170 to indicate the patient refused to have an x-ray. 10. For services other than m anual manipulation to treat a subluxation of the spine, performed by a chiropractic physician, the HCPCS code A9170 may be submitted for denial. 11. Manual manipulation performed as maintenance therapy should also be coded using A If the chiropractic physician believes that manipulation services may be considered not to be reasonable and necessary, he/she may have the beneficiary sign a waiver of liability statement. The waiver must indicate the specific reason why the chiropractor believes Medicare may not reimburse the service. The service should be submitted with a GA modifier, indicating that a waiver has been obtained, and include a copy of the waiver if submitting a paper claim. The GA m odifier is informational only and does not trigger an automatic denial, i.e., the service could be paid by Medicare. Therefore, the provider should wait for the claim to be processed before billing the beneficiary for a denied service subject to the waiver of liability. Documentation Requirements: 1. All claim s m ust include the primary and secondary ICD-9-CM codes to reflect medical necessity. Claims lacking these ICD-9-CM codes will be rejected. 2. Claim s m ay be submitted via paper or electronically. 3. The precise level of subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. The level of spinal subluxation must bear a direct causal relationship to the patient's symptoms, and the symptoms must be directly related to the level of the subluxation that has been diagnosed. Area of Spine Names of Vertebrae N Number of Vertebrae Short Form or other Name Neck Back Occiput Cervical Atlas Axis Dorsal Thoracic Costovertebral Costotransverse 7 Occ, CO C1 thru C7 C1C1 C2C2 12 D1thru D12 T1 thru T12 R1thru R12 R1thru R12 Low Back Lumbar 5 L1 thru L5 Pelvis Ilii,r, and l I, SI Sacral Sacrum, Coccyx S, SC 4. The following information must be documented in the patient's medical record for the Initial Visit, whether the subluxation is demonstrated by x-ray or by physical examination: A. History: # Chief com plaint including the symptoms present that caused the patient to seek chiropractic treatment # Familty history if relevant # Past health history including: general health statement, prior illness(es), surgical history, prior injuries or trauma, past hospitalizations (as appropriate), medications. B. Description of present illness including: # Mechanism of trauma;

9 # Quality and character of problem/symptoms; # Onset, duration, intensity, frequency, location and radiation of symptoms; # Aggravating or relieving factors; # Prior interventions, treatments, medications, secondary complaints; and # Symptoms causing patient to seek treatment. These sym ptoms m ust bear a direct relationship to the level of subluxation. The sym ptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems, as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but, in general, other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined. C. Evaluation of musculoskeletal/nervous system through physical examination. D. Diagnosis: The primary diagnosis must be subluxation, and must indicate the level of the subluxation. The secondary diagnosis (category I, II, or III) must reflect the neuromusculoskeletal condition necessitating the treatment. E. Treatment Plan: The treatment plan should include the following: # Recommended level of care (duration and frequency of visits); # Specific treatment goals; and # Objective measures to evaluate treatment effectiveness. F. Date of initial treatment or date of exacerbation 5. The following documentation is required for Subsequent Visits: A. History, including: # review of chief complaint; # changes since last visit; # system review if relevant. B. Physical examination, including: # exam of area of spine involved in diagnosis; # assessment of change in patient condition since last visit; # evaluation of treatment effectiveness. C. Docum entation of treatment given on day of visit. 6. X-rays/MRI/CT Scan o For dates of service prior to January 1, 2000, a documenting x-ray, (or existing MRI or CT scan) must have been taken at a time reasonably proximate to the initiation of a course of treatm ent, unless in the carrier's judgm ent more specific diagnostic imaging evidence is warranted. An x-ray, (or existing MRI or CT scan) is considered by Medicare to be "reasonably proximate" if it was taken no more than twelve (12) months prior to, or three (3) months following the initiation of a course of treatment. o In certain cases of chronic subluxation, an older x-ray (or existing MRI or CT scan) may be accepted, provided the beneficiary's health record indicates the condition has existed longer than twelve (12) months, and there is reasonable grounds for concluding that the condition is chronic. o Effective for claims with dates of service on or after January 1, 2000, an x-ray is not required to demonstrate the subluxation. However, an x-ray may be used for this purpose if the chiropractor so chooses. If an x-ray is used for documentation, the criteria that applies to services performed prior to January 1, 2000, apply. o The use of an existing MRI or CT scan has been approved by the Centers for Medicare & Medicaid Services (CMS) for Medicare purposes to determine the diagnosis of subluxation for chiropractic manipulations. However, the chiropractor is limited to referring the patient for x- rays. o Videofluoroscopy of the spine is not an accepted method for diagnosing subluxation for chiropractic manipulation.

10 o The x-ray/mri/ct scan must be made available to Medicare when requested. If the diagnostic studies have been taken in a hospital or outpatient facility, a written report, including interpretation and diagnosis by a physician must be present in the patient's medical record. o The chiropractor's review of the x-ray (or existing MRI or CT scan) should be documented, noting the level of subluxation. The film(s) must be labeled with the patient's name and date they were taken, and must be marked right or left. o A chiropractor may not order an x-ray (or other diagnostic study), but he/she may refer the beneficiary for an x-ray. The authorized ordering practitioner in turn may accept a referral for an x-ray. The authorized ordering practitioner must maintain adequate docum entation to support the medical necessity for the service. o Section 2250 of the Medicare Carrier s Manual stipulates that judgements about the reasonableness of chiropractic treatm ent must be based on the application of chiropractic principles. Therefore, the Centers for Medicare & Medicaidation has determined that if the opinions of a radiologist and a chiropractor conflict as to the existence of a subluxation (for a chiropractic patient), then the opinion of the chiropractor takes precedence. 7. The P.A.R.T. evaluation process is recommended as the examination alternative to the previously mandated demonstration of subluxation by x-ray/mri/ct for services beginning January 1, The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation). P - Pain/tenderness: The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest primarily by a painful response. Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation, provocation, etc. Furthermore, pain intensity may be assessed using one or more of the following; visual analog scales, algometers, pain questionnaires, etc. A - Asymmetry/misalignment: Asymmetry/misalignment may be identified on a sectional or segmental level through one or more of the following: observation (posture and heat analysis), static palpation for misalignment of vertebral segments, diagnostic imaging, etc. R - Range of motion abnormality: Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following: motion palpation, observation, stress diagnostic imaging, range of motion, measurement(s), etc. T - Tissue tone, texture, temperature abnormality: Changes in the characteristics of contiguous and associated soft tissue including skin, fascia, muscle and ligament may be identified through one or more of the following procedures: observation, palpation, use of instrumentation, test of length and strength, etc. o o o To demonstrate a subluxation based on physical examination, two of the four criteria mentioned above are required, one of which must be asymmetry/misalignment or range of motion abnormality. The findings derived from the P.A.R.T. evaluation can be used to decide which areas are in need of an adjustment. The clinical decision as to whether an adjustment will be made, how it is done, where and when it is applied can be determined by which area has the most findings from each category. The evaluation process must be an ongoing procedure. Even if a complete and thorough examination can be completed during the first visit, signs and certain symptoms must be rechecked during the course of treatm ent to determine the extent of the patient progress. This ongoing evaluation and assessment forming the basis for treatm ent modification is a key factor in total patient managem ent. The initial examination, no matter how thorough, cannot be expected to provide all the answers. A treatment trial should be instituted with its effects assessed to determine whether it should be continued or a different plan devised. Moreover, it is the examination that forms the foundation for treatment, guiding the doctor in selecting appropriate

11 treatm ent techniques, frequency, and course of treatment. 8. The Carrier will seek consultation from a chiropractic physician to evaluate medical records, as necessary. 9. Documentation must be legible and must be available to Medicare upon request. Failure to provide this may result in denial of claim(s). Utilization Guidelines: It would be unusual for more than the following numbers of treatments to be necessary for the sites indicated. Exceeding these guidelines may prompt additional medical reviews: Level of Spine: Acute condition Recurrence or chronic condition Cervical 9-15 services Additional 7 services per year Thoracic 6-10 services Additional 5 services per year Lumbosacral services Additional 10 services per year Other Comments:! For services that exceed the accepted standard of m edical practice and may be deemed not medically necessary, the provider/supplier must provide the patient with an acceptable advance notice of Medicare s possible denial of payment. A waiver of liability should be signed when a provider/supplier does not want to accept financial responsibility for the service.! This policy was developed to update New York State chiropractic coverage in accordance with changes in MCM sections 2251 and 4118.! This policy supersedes Empire s policy Ymed #06, all revisions. Sources of Information! Foundations of Chiropractic Quality Assurance and Practice Parameters; Gatterman. Mosby Year Books, 1995! Guidelines for Chiropractic Quality Assurance and Practice Parameters; ed. Haldeman, Chapman- Smith, Peterson. Aspen Publication, 1993! Chiropractic Physician Consultants! Other Medicare Part B carriers' local medical review policies, e.g., Colorado, Iowa, Kansas, Michigan, Empire New Jersey, Upstate Medicare Division, NY. Advisory Committee Notes:! The policy was presented at the September 13, 2000 Carrier Advisory Committee (CAC) meeting by Empire Medicare Services.! This policy does not reflect the sole opinion of the carrier or the carrier medical director. Although the final decision rests with the carrier, this policy was developed in cooperation with the Carrier Advisory Committee, which includes representatives from the New York State Chiropractic Association, the New York State Academy of Family Physicians, the New York State Society of Internal Medicine, and the Medical Society of the State of New York. Start Date of Comment Period: 09/13/2000 End Date of Comment Period: 10/28/2000 Start Date of Notice Period: 12/29/2000 Revision History: Paul G. Deutsch, MD Associate Carrier Medical Director Norbert W. Rainford, MD Carrier Medical Director