Revision Date 11/20/2018

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1 Page 1 of 10 This document applies to the following Participating Organizations: EHP Johns Hopkins Advantage MD Priority Partners US Family Health Plan Keywords: Chiropractic, Spinal Manipulation Table of Contents Page Number I. ACTION 1 II. POLICY DISCLAIMER 1 III. POLICY 1 IV. POLICY CRITERIA 2 V. DEFINITIONS 2 VI. BACKGROUND 3 VII. CODING DISCLAIMER 3 VIII. CODING INFORMATION 4 IX. REFERENCE STATEMENT 9 X. REFERENCES 9 XI. APPROVALS 10 I. ACTION New Policy X Revising Policy Number Superseding Policy Number Archiving Policy Number Retiring Policy Number CMS04.04 II. POLICY DISCLAIMER Johns Hopkins HealthCare LLC (JHHC) provides a full spectrum of health care products and services for Employer Health Programs, Priority Partners, Advantage MD and US Family Health Plan. Each line of business possesses its own unique contract and guidelines which, for benefit and payment purposes, should be consulted to know what benefits are available for reimbursement. Specific contract benefits, guidelines or policies supersede the information outlined in this policy. III. POLICY For Advantage MD see: Local Coverage Determination (LCD) L35424, Medicare Coverage Database Medicare does not have a National Coverage Determination (NCD) for. For PPMCO see:

2 Page 2 of 10 Code of Maryland Regulations (COMAR) Benefits - EPSDT Services For USFHP see: TRICARE. Policy Manual M, February 1, Chiropractic Manipulative Treatment (CMT): Chapter 7, Section 18.5 manuals.tricare.osd.mil/ IV. POLICY CRITERIA A. When benefits are provided under the member s contract, JHHC considers spinal manipulation services medically necessary for acute neuromusculoskeletal conditions of the spine and for an acute exacerbation of a chronic condition when there is an expectation of functional improvement. B. Clinical documentation must demonstrate the member has a significant neuromusculoskeletal condition, creating a functional impairment, necessitating appropriate, medically necessary evaluation and treatment, and there must be a reasonable expectation of recovery or improvement of function. C. Clinical documentation must show improvement as evidenced by successive objective measurements over a defined time frame and documented progress toward therapeutic goals. D. Unless specific benefits are provided under the member s contract, JHHC considers spinal manipulation services for the treatment of non-neuromusculoskeletal disorders including, but not limited to, infantile colic, bronchitis, enuresis, asthma, allergies, otitis media, attention deficit hyperactivity disorder (ADHD), reading difficulty in children, hypertension, constipation, gastrointestinal disorders, infections, fatigue, idiopathic scoliosis, or mental and nervous conditions experimental and investigational, as they do not meet Technology Evaluation Criteria (TEC). E. Unless specific benefits are provided under the member s contract, JHHC considers spinal manipulation services for the treatment of children less than six years old experimental and investigational, as they do not meet Technology Evaluation Criteria (TEC). F. Unless specific benefits are provided under the member s contract, JHHC considers spinal manipulation under general anesthesia, in the absence of vertebral fracture, experimental and investigational as it does not meet Technology Evaluation Criteria (TEC). G. Spinal manipulation for the treatment of chronic conditions when there is no expectation of improvement, or to preserve present level of function, or prevent regression is considered not medically necessary. H. Continued chiropractic care to maintain health or when the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, i.e. maintenance care is considered not medically necessary (Refer to Definitions). V. DEFINITIONS Acute pain: An expected physiologic experience to noxious stimuli that can become pathologic, is normally sudden in onset, time limited, and motivates behaviors to avoid actual or potential tissue injuries (NIH, 2016). Back pain: A. Acute back pain is defined as lasting less than 4 weeks B. Subacute back pain lasts 4 to 12 weeks C. Chronic back pain lasts more than 12 weeks. (ACP, 2017) Chronic pain: Pain that occurs on at least half the days for six months or more (NIH, 2016).

3 Page 3 of 10 Maintenance therapy: A treatment plan that seeks to prevent disease or, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy (Medicare Benefit Policy Manual, Ch. 15, 30.5 B). VI. BACKGROUND Under Maryland law the practice of chiropractic is described as the use of a drugless system of health care based on the principle that interference with the transmission of nerve impulses may cause disease. The practice of chiropractic includes the diagnosing and locating of misaligned or displaced vertebrae and, through the manual manipulation and adjustment of the spine and other skeletal structures, treating disorders of the human body(annotated Code of Maryland, Health Occupations 3-101). In Maryland, the Board of Chiropractic Examiners issues two types of licenses, a license permitting the holder to practice chiropractic and a license covering the practice of chiropractic and physical therapy (COMAR ). According to the World Health Organization s Guidelines on Basic Training and Safety in Chiropractic, chiropractic is a health care profession concerned with the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. There is an emphasis on manual techniques, including joint adjustment and/or manipulation, with a particular focus on vertebral subluxation (WHO, 2016). During chiropractic adjustment or manipulation, the chiropractor typically uses his or her hands, or an instrument, to manipulate the joints of the body, particularly the spine, with a goal of restoring joint function, resolving joint inflammation and reducing pain. There are varying opinions within the medical community regarding the effectiveness of manual therapies. The majority of studies highlighting the benefits of manual therapies involved patients with neck/joint/back pain or musculoskeletal issues. However, there is limited high quality evidence demonstrating the effectiveness of manual therapy for the treatment of other chronic conditions (Clar, 2013). Confident judgments cannot be made about the safety or effectiveness of manual therapy interventions for non-musculoskeletal disorders due to these limitations in study quantity and quality (Optum, 2018). Furthermore, there is limited research on the effectiveness of chiropractic manipulation as a form of preventive care. Chiropractic services administered for preventative or maintenance purposes are not covered. Chiropractic care is the most common complementary and integrative medicine practice used by children in the United States, however, the scientific evidence for the efficacy of chiropractic care and spinal manipulation for the treatment of children is not plentiful or definitive (Hawk, 2016). Additionally, high quality studies, directly focused on identifying adverse events with use of manual therapies in the pediatric population is lacking (Humphreys, 2010). According to COMAR EPSDT Services, chiropractic care for children is covered, and services are subject to limitations only on the basis of medical necessity. Due to the paucity of evidence in this age group, JHHC considers chiropractic care not medically necessary for the treatment of infants and children under six years old. VII. CODING DISCLAIMER CPT Copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Note: The following CPT/HCPCS codes are included below for informational purposes. Inclusion or exclusion of a CPT/ HCPCS code(s) below does not signify or imply member coverage or provider reimbursement. The member s specific benefit plan determines coverage and referral requirements. All inpatient admissions require preauthorization.

4 Page 4 of 10 Employer Health Programs (EHP) refer to specific Summary Plan Description (SPD). If there is no criteria in the SPD, apply the Medical Policy criteria. Compliance with the provision in this policy may be monitored and addressed through post payment data analysis and/or medical review audits Priority Partners (PPMCO) refer to COMAR guidelines and PPMCO SPD then apply the criteria. US Family Health Plan (USFHP), TRICARE Medical Policy supersedes JHHC. If there is no Policy in TRICARE, apply the Criteria. Advantage MD, LCD and NCD supersedes JHHC Medical Policy. If there is no LCD or NCD, apply the Medical Policy Criteria. VIII. CODING INFORMATION NO PREAUTHORIZATION REQUIRED CPT CODES DESCRIPTION Chiropractic manipulative treatment (CMT); spinal, one to two regions Chiropractic manipulative treatment (CMT); spinal, three to four regions Chiropractic manipulative treatment (CMT); spinal, five regions Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions S8990 HCPCS CODE DESCRIPTION Physical or manipulative therapy performed for maintenance rather than restoration. ICD10 AND REVENUE CODES ARE FOR INFORMATIONAL PURPOSES ONLY ICD10 Codes G24.3 Spasmodic torticollis G G G G44.89 Migraine Tension and other headaches G G55 Nerve root and plexus disorders DESCRIPTION

5 Page 5 of 10 G G56.93 Mononeuritis of upper limb G G59 Mononeuritis of lower limb G G72.9 Muscular dystrophies and other myopathies G G80.9 Cerebral palsy M M08.99 M M13.89 M M19.93 M M25.9 Rheumatoid arthritis and other inflammatory polyarthropathies Other and unspecified arthropathies Osteoarthritis and allied disorders Other joint disorders M35.3 Polymyalgia rheumatica M M40.51, M M54.9 M M60.9 M M62.49 M M75.9 M M85.39 M M89.09 M M94.9 Deforming dorsopathies, spondylitis and other dorsopathies Other myositis Contracture of muscle Rheumatism, shoulder lesions and enthesopathies Osteitis condensans Algoneurodystrophy Osteochondropathies M95.3 Acquired deformity of neck M95.5 Acquired deformity of pelvis M95.8 Other specific acquired deformities of musculoskeletal system M95.9 Acquired deformity of musculoskeletal system, unspecified M M99.9 Other biomechanical lesions

6 Page 6 of 10 M M99.84 Other acquired deformity of back or spine Q Q68.8 Congenital musculoskeletal deformities Q74.0 Other congenital malformations of upper limb(s), including shoulder girdle Q Q74.2 Congenital malformations of lower limb, including pelvic girdle Q74.9 Unspecified congenital malformation of limb(s) Q76.0 -Q76.49 Congenital malformations of spine Q Q77.1, Q Q77.5, Q Q77.9, Q78.9 R51 S13.0xx+ - S13.9xx +, S23.0xx + - S23.9xx +, S33.0xx + - S33.9xx +, S S43.92X +, S S53.499, S S63.92X+, S S , S S83.92X+, S93.01X+ - S S14.2XX+ - S14.9XX+, S24.2XX+ - S24.9XX+, S34.21X+ - S34.9XX+ S16.1xx+ Osteochrondrodysplasia Headache Dislocation and sprains of joint and ligaments Injuries to nerve root(s), spinal plexus(es) and other nerves Strain of muscle, fascia and tendon at neck level

7 Page 7 of 10 S23.41X+ - S , S33.4XX+, S33.8XX+ - S34.9XX+ S , S , S S44.00X+ - S44.92X+ S S , S S , S S , S S , S S , S S S74.00X+ - S74.92X+ S S , S S , S S , S S , S S , S S S84.00X+ - S84.92X+ Sprain of other ribs, sternum, and pelvis Injury or strain of muscle, fascia and tendon of lower back Injury of nerves at shoulder and upper ar level Injury of muscle, fascia and tendon at shoulder and upper arm level Injury of nerves at hip and thigh level Injury and strain of muscle, fascia and tendion at hip and thigh level Injury of nerves at lower leg

8 Page 8 of 10 S S , S S , S S , S S , S S , S S S S , S S , S S , S S , S S , S S S S , S S S , S S , S S Injury of muscle, fascia and tendon at lower leg level Injury of nerves at ankle and foot level Injury of muscle, fascia and tendon at ankle and foot level Revenue Codes 0420 Physical Therapy-General; Hospital; outpatient 0430 Occupational Therapy-General; Hospital; outpatient 0940 Other Therapeutic Services; Hospital; outpatient DESCRIPTION

9 Page 9 of 10 IX. REFERENCE STATEMENT Analyses of the scientific and clinical references cited below were conducted and utilized by the Johns Hopkins HealthCare LLC (JHHC) Team during the development and implementation of this medical policy. Per NCQA standards, the Team will continue to monitor and review any newly published clinical evidence and adjust the references below accordingly if deemed necessary. X. REFERENCES Aetna. (2017). Clinical Policy Bulletin:. Number Retrieved: Annotated Code of Maryland, Health Occupations Retrieved: (2018) CareFirst. (2017) : Spinal Manipulation and Related Services. Retrieved: secure.compliance360.com Centers for Medicare and Medicaid Services (CMS). (2018). Medicare Coverage Database. Retrieved: Centers for Medicare and Medicaid Services (CMS). (2018). Medicare Benefit Policy Manual Chapter 15, Covered Medical and Other Health Services, 30.5 Chiropractor's Services. Retrieved: Chou, R. (2018). Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment. UptoDate. Retrieved: Clar, C., Tsertsvadze, A., Court, R., et al. (2014). Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropractic & Manual Therapies, Vol. 22, Issue 12, epub. Code of Maryland Regulations, (2018). Title 10, Maryland Department of Health, Subtitle 43, Board of Chiropractic Examiners. Retrieved: COMAR J Cooper, R.A., McKee, H.J. (2003). Chiropractic in the United States: Trends and Issues, The Millbank Quarterly, Vol. 81, Issue 1, p Dobson, D., Lucassen, P.L.B.J., Miller, J.J., et al. (2012). Manipulative therapies for infantile colic. Cochrane Review. Retrieved: Ferrance, R.J., Miller, J. (2010). Chiropractic diagnosis and management of non-musculoskeletal conditions in children and adolescents. Chiropractic & Osteopathy. Vol. 18, Issue 14. Retrieved: Humphreys, B. K. (2010). Possible adverse events in children treated with manual therapy: a review. Chiropractic & Osteopathy. Vol. 18, Issue 12. Retrieved: Hawk, C., Schneider, M. J., Vallone, S, Hewitt, E. G. (2016). Best Practices for Chiropractic Care of Children: A Consensus Update. Journal of Manipulative and Physiological Therapeutics. Volume 39, Issue 3. Pages Retrieved: Issac, Z. (2018). Treatment of neck pain. UptoDate. Retrieved: Kemper, K.J. (2018). Complementary and alternative medicine in pediatrics. UptoDate. Retrieved:

10 Page 10 of 10 Kemper, K.J., Vohra, S., Walls, R. (2008). The Use of Complementary and Alternative Medicine in Pediatrics. Pediatrics: Official Journal of the American Academy of Pediatrics, Vol. 122, Issue 6, p Knight, C.L., Deyo, R.A., Staiger, T.O., Wipf, J.E. Treatment of acute low back pain. (2018). UptoDate. Retrieved: National Institute of Health and Care Excellence (NICE). (2016). Low back pain and sciatica in over 16s: assessment and management Guideline NG59. Retrieved: National Institutes of Health. (2016). National Pain Strategy; A Comprehensive Population Health-Level Strategy for Pain. Retrieved: National Institutes of Health. (2017). /National Center for Complementary and Integrative: 7 Things to Know About Mind and Body Practices for Children and Teens. Retrieved: National Institutes of Health. (2017). National Center for Complementary and Integrative Health: The Use of Complementary and Alternative Medicine in the United States. Retrieved: Optum. (2018). Utilization Management Policy: Manual Therapy Interventions for Non-Musculoskeletal Disorders. Retrieved: Qaseem, A., Wilt, T.J., McClean, R.M., Forciea, M.A. Clinical Guideline Committee for the American College of Physicians (ACP). (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Retrieved: Shekelle, P., Vernon, H. (2018). Spinal manipulation in the treatment of musculoskeletal pain. UptoDate. Retrieved: Sutton Hamilton, S. (2018) Reading difficulties in children. UptoDate. Retrieved: Théroux, J., Stomski, N., Losco, C. D., et al. (2017). Spinal Manipulative Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review. Journal of Manipulative and Physiological Therapeutics, Vol. 40, Issue 6, p TRICARE. Policy Manual M, February 1, Chiropractic Manipulative Treatment (CMT): Chapter 7, Section Retrieved: World Health Organization (WHO). (2005). Guidelines on Basic Training and Safety in Chiropractic. Retrieved: XI. APPROVALS Historic Effective Date: 03/06/2015; 03/03/2017; 11/20/2018