Medical Affairs Policy

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1 Service: Chiropractic Services PUM Medical Affairs Policy Medical Policy Committee Approval 03/16/18 Effective Date 07/01/18 Prior Authorization Needed No Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health to assist in administering health benefits. This medical policy and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, medical.policies@wpsic.com. Description: Chiropractic care is used most often to treat neuromusculoskeletal complaints including low back and neck pain, sciatica, joint pain, and headaches. Chiropractors also treat individuals with osteoarthritis, spinal disc conditions, carpal tunnel syndrome, tendonitis, and sprains and strains. Chiropractic treatments usually involve spinal manipulation, other manual techniques (joint manipulation / mobilization), and muscle soft tissue techniques, as well as a variety of modalities, including but not limited to: thermal therapies (Heat or Cold), corsets or braces, ultrasound, strength and conditioning exercise instruction, and electrotherapy. Chiropractic care also includes appropriate instruction on activity modification, exercise, and self-care. Medically necessary chiropractic services are performed to improve an individual s abilities to complete their activities of daily living (ADL). Typical activities of daily living include personal hygiene tasks, dressing and undressing, eating, transferring from bed to chair and ambulation. Individuals may also have severe functional limitations that decrease their ability to perform their activities of daily living. Chiropractic services designed to treat the functional limitation usually result in an improved ability to perform activities of daily living. Services are not generally indicated for the management of pain alone when there is no functional limitation. Page 1 of 14

2 Indications of Coverage: For ALL chiropractic services, the following must be documented: 1. The member has a musculoskeletal disorder. Headache may be considered a musculoskeletal disorder 2. Date of visit and name of treating provider 3. Hand-written documentation must be legible 4. Evaluation and Management (E&M) billing code level must be supported by the provider s documentation 5. ICD-10 diagnostic code(s) must be supported by the provider s documentation 6. Chiropractic manipulative therapy (CMT) coding: a. Primary segmental dysfunction results in functional loss which when treated is medically necessary. b. Secondary segmental dysfunction is compensatory which when treated is clinically appropriate but not medically necessary. c. Therefore, the provider s documentation must match the primary segmental dysfunction level(s) resulting in functional loss with the CMT code selected. The provider is not to count secondary segmental dysfunction levels with the code selected. 7. Modalities (Thermal therapies, ultrasound, electrotherapy, and low level laser therapy as per section E. 1-3): a. Documentation of the rationale for use. b. Time component must be documented. c. Modality machine settings (i.e. intensity, depth, etc.) must be documented. d. Only 1 modality per anatomic area. e. After 6 weeks, the use of passive modalities is considered not medically necessary for an episode of care. 8. Active care (i.e., Strength and condition exercise instruction, neuromuscular reeducation of movement, gait training): a. Documentation of the specific exercise(s) and/or activity(ies) and the rationale for implementation. Page 2 of 14

3 9. Date of onset on the Health Care Financing Administration (HCFA)/Centers for Medicare and Medicaid Services (CMS) form must be related to the current episode of care and correlate with the clinical documentation. 10. Delegated massage therapy (if not an exclusion of the health plan) a. Documentation of the rationale for use in the current treatment plan. b. Frequency and duration must be documented in the current treatment plan. c. Documentation of specific goals to improve ADLs in the current treatment plan. d. Documentation of objective measures to evaluate treatment effectiveness in the current treatment plan. e. Treatment time documented for each session. f. Documentation of manual assessment of the spine/body area to be treated on each session. g. Documentation of the manual treatment which must correlate with the location of symptoms and physical findings on each session. h. Massage therapy which does not demonstrate functional improvement upon re-assessment is considered maintenance/custodial 11. Note: National Correct Coding Initiative (NCCI) claim edits bundle manual therapy to chiropractic adjustment codes when performed in the same anatomic region. A. The initial visit is considered medically necessary when documentation includes ALL the following: 1. Date of visit and name of treating provider 2. Health History a. Symptoms causing patient to seek treatment; b. Family history if relevant; c. Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history); d. Mechanism of trauma; e. Quality and character of symptoms/problem; f. Onset, duration, intensity, frequency, location and radiation of symptoms; g. Aggravating or relieving factors; and Page 3 of 14

4 h. Prior interventions, treatments, medications, secondary complaints i. Documentation of complicating factors j. Documentation as to whether or not the patient has any absolute or relative contraindications to manipulation present. 3. Physical Exam a. Exam of spine/area of the body involved in diagnosis 4. Effect of condition/diagnosis on current activities of daily living (ADL) 5. Treatment plan includes all of the following: a. Planned duration and frequency of visits b. Specific treatment goals; and c. Objective measures to evaluate treatment effectiveness: documentation of measurable goals of treatment (e.g. Oswestry index, specific improvements in ADL, decreased pain level) 6. Documentation of informed consent B. Subsequent visits are considered medically necessary when documentation includes ALL the following: Note: Progress toward goals /improvement is documented within the first two (2) weeks of treatment (See Limitations of Coverage, letter D). 1. Date of visit and name of treating provider for each encounter 2. Document treatment # (number) of # (total treatments) for the current episode of care (i.e. Treatment #5 of 8) for each subsequent visit. 3. Focused physical exam: area of spine/body involved in diagnosis 4. Documentation of all treatments on the day of visit. Note: treatments must correlate with the location of symptoms and physical findings Page 4 of 14

5 5. Documentation of progress (or lack of progress) toward previously identified goals 6. Revised goal (when applicable- e.g. plan modified due to no improvement with current plan) C. Subsequent visits beyond four weeks of treatment are considered medically necessary provided: re-evaluation of the current treatment plan is documented at a minimum of every four weeks. Based on the re-evaluation, an updated treatment plan is documented which includes: 1. Planned duration and frequency of visits 2. Documented changes in outcome assessment measures compared to baseline &/or most recent re-evaluation & treatment plan 3. Documentation of continued measurable progress toward each goal to include whether or not goal has been met. Goals should be updated and modified as appropriate 4. Modification of treatment interventions as appropriate in order to meet goals 5. Documentation of advice, activity modification and exercise implementation as appropriate to assist in achievement of goal(s) 6. Documentation of collaboration with other health providers as appropriate to assist in achievement of goal(s) D. Spinal Manipulation is considered medically necessary when ALL the following are documented: 1. Documentation of history, physical and treatment as indicated above including the following: a. No evidence of acute, fracture, dislocation, or rupture b. No evidence of acute infection c. No evident of tumor d. No evidence of active flare of Rheumatoid Arthritis or Severe Osteoporosis at the level of spinal manipulation OR documentation that supports using the modality in spite of this relative contraindication Page 5 of 14

6 e. Spinal manipulation is a component of a comprehensive multimodal treatment plan f. Symptoms significantly impact ADL g. Spinal pain as indicated by one or more of the following: i. Back pain when ALL the following are present: a) Absence of signs and symptoms associated with other serious pathologic conditions b) Acute low back pain OR c) Recent worsening of symptoms in an individual with chronic (lasting more than 12 weeks) or stable low back pain ii. Coccydynia (Coccyx pain) and ALL the following: a) Duration less than 1 year b) Stress x-rays show stable coccyx c) Traumatic mechanism of injury iii. Neck Pain and ALL the following: a) Absence of inconsistent signs and symptoms that may be associated with other serious pathologic conditions b) Absence of signs and symptoms of cord compression (i.e., no lower extremity weakness) c) Absence of signs and symptoms of impending vertebrobasilar artery stroke E. Low level laser also known as cold laser or class III laser is considered medically necessary when ALL (1 through 3) of the following are documented: 1. Confirmed diagnosis of ONE of the following: a. Carpal tunnel syndrome b. Lateral epicondylitis Page 6 of 14

7 c. Rheumatoid arthritis 2. No acute untreated arthritis exacerbation 3. No treatment over growth plates in a child F. Infrared light treatment as a heat modality is considered incidental to the other evaluation and management chiropractic series and is not reimbursed separately G. X-ray/CT/MRI is considered medically necessary when: 1. History and physical exam supports the rationale for imaging, any suspected pathology, or what is being ruled out 2. Full spine radiograph is considered medically necessary for scoliosis only H. The following modalities and devices are considered medically necessary when there is documentation of the rationale for use: 1. Corsets or braces 2. Relaxation therapy. Note: This is often an exclusion of the member certificate of coverage 3. Custom and premade orthotics are often an exclusion of the health plan. When coverage is available, custom orthotics are considered medically necessary when all the following are present: a. Arch, heel, or other foot pain b. One of the following foot conditions: i. Cerebral palsy (diplegic) ii. Juvenile idiopathic arthritis iii. Pes cavus iv. Rheumatoid arthritis v. Plantar fasciitis symptoms present for three (3) or more months and failure of all the following to improve symptoms: a) Changes in activities to improve symptoms Page 7 of 14

8 Limitations of Coverage: b) Anti-inflammatory medications (1month trial) c) Stretching of calf muscles and plantar surface d) Use of prefabricated orthotics A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements B. If used for a condition/diagnosis other than as listed in the Indications of Coverage, deny as experimental, investigational, and unproven to affect health outcomes C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, deny as not medically necessary D. If no improvement is documented within the initial 2 weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified E. If no improvement is documented within 30 days, despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary F. Once the maximum therapeutic benefit has been achieved, continuing chiropractic care is considered not medically necessary G. Chiropractic manipulation in asymptomatic persons or in persons without an identifiable clinical condition is considered not medically necessary H. Chiropractic care in persons whose condition is neither regressing nor improving, is considered not medically necessary I. Long term therapy and maintenance therapy, maintenance care, and or supportive care may be exclusions of the member s health plan. J. Work hardening, vocational rehabilitation, and industrial rehabilitation may be exclusions of the member s health plan. K. Manipulation is considered experimental, investigational, and unproven to affect health outcomes when it is rendered for internal or non-neuromusculoskeletal conditions including, but not limited to: autism, infant colic, otitis media, asthma, Page 8 of 14

9 attention-deficit hyperactivity disorder, dysmenorrhea, epilepsy, and gastro-intestinal disorders L. Routine imaging as part of an initial evaluation, or repeat imaging to determine the progress of conservative or ongoing treatment is considered not medically necessary M. Full spine radiographs for any condition other than scoliosis is considered not medically necessary N. Dynamic spinal visualization (including digital motion x-ray and video fluoroscopy, also known as cineradiography) is considered not medically necessary O. Any laboratory services for which the office is not CLIA (Clinical Laboratory Improvement Amendments) certified or falls outside of the scope of practice, including, but not limited to: drug testing, therapeutic drug assays, genetic testing, and organ or disease oriented panels is considered experimental, investigational, and unproven to affect health outcomes P. Low level laser therapy is considered experimental, investigational, and unproven to affect health outcomes for any conditions not listed in the indications including, but not limited to: 1. Achilles tendinopathy 2. Adhesive capsulitis 3. Fibromyalgia 4. Low back pain 5. Myofascial pain 6. Neck Pain 7. Osteoarthritis 8. Plantar fasciitis 9. Subacromial impingement syndrome 10. Temporal mandibular syndrome Page 9 of 14

10 Q. Some of the following services may be exclusions of the member s health plan. In the absence of a specific member certificate exclusion or limitation, the following procedures are also considered experimental, investigational, and unproven to affect health outcomes: 1. Active Therapeutic Movement (ATM2) 2. Advanced Biostructural Correction (ABC) Chiropractic Technique 3. Applied Kinesiology 4. Applied Spinal Biomechanical Engineering 5. Atlas Orthogonal Technique 6. Bioenergetic Synchronization Technique (BEST) 7. Biofeedback 8. Biogeometric Integration 9. Blair Technique 10. Bowen Technique 11. Chiropractic Biophysics Technique 12. Chiropractic services directed at controlling progression and/or reducing scoliosis, including but not limited to the SpineCor brace and CLEAR scoliosis treatment 13. Coccygeal Meningeal Stress Fixation Technique 14. Computerized muscle testing or analysis 15. Computerized radiographic mensuration analysis for assessing spinal malalignment 16. Cranial Manipulation 17. Craniosacral/Cranial sacral therapy 18. Directional Non-Force Technique 19. Dry Needling Page 10 of 14

11 20. Gonzalez Rehabilitation Technique 21. Hair Analysis 22. Home Biofeedback Units 23. Home cold therapy units (cryotherapy machines and cryotherapy units) 24. Home spinal traction units 25. Hako-Med lectrotherapy (horizontal electrotherapy) 26. Impulse adjusting instrument (Arthrostim) 27. Kinesio taping (Elastic Therapeutic Taping) 28. Koren Specific Technique 29. Live cell Analysis 30. Manipulation under Anesthesia (consider scope of practice) 31. Moire Contourographic Analysis 32. Nambudripad s Allergy Elimination Technique (NAET) or other Allergy Testing 33. National Upper Cervical Chiropractic Association (NUCCA technique) or Grostic technique 34. Network Chiropractic, NeuroEmotional Technique (NET) 35. Network Technique 36. Neural Organizational Technique, Contact Reflex Analysis (CRA), Whole System Scan 37. Neuro Emotional Technique 38. Neurocalometer, Nervoscope, Nerve Conduction Velocity, Surface EMG, Paraspinal Electromyography, Spinoscopy, or other nerve conducting testing 39. Neurocalometer/Nervoscope Page 11 of 14

12 40. Neurocranial Restructuring (NCR) 41. Para-spinal electromyography (EMG) or Surface scanning EMG 42. Pettibon technique, system and Pettibon products including the Wobble chair 43. Spinoscopy 44. Spinal Diagnostic Ultrasound 45. Therapeutic (Wobble) Chair 46. Treatment for brachioradial pruritus 47. Upledger Technique 48. Vascular studies including, but not limited to, Doppler ultrasound analysis and plethysmography 49. VAX-D, Lordex, LTX3000, DRX-9000, DRS (Decompression Reduction Stabilization System), or other back traction devices charged at a higher rate than mechanical traction 50. Webster Technique (for breech babies) 51. Whitcomb Technique 52. Whole Body Vibration (WBV), Vibration Plate, Vibration Therapy 53. Other services not on this list may be considered investigational, experimental, and unproven to affect health outcomes based upon medical review of submitted claims and documentation Documentation Required: Office notes Page 12 of 14

13 References: 1. MCG 22 nd ed. ACG: A-0331 Spinal Manipulation Therapy (SMT), Chiropractic and Other 2. MCG 22 nd ed. ACG: A-0511 Laser Therapy, Low-level 3. MCG 22 nd ed. ACG: A-0700 Cryounits and Cryotherapy Machines 4. MCG 22 nd ed. ACG: A-0330 Biofeedback 5. UpToDate Spinal Manipulation in the Treatment of Musculoskeletal Pain. Topic last updated January 10, Literature review current through Feb UpToDate Treatment of acute Low Back Pain. Topic last updated: December 06, Literature review current through Feb UpToDate Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment. Topic last updated Oct 31, Literature review current through Feb Council on Chiropractic Guidelines and Practice Parameters ( 9. Center for Medicare and Medicaid Services (CMS) Local Coverage Determination (LCD) L /01/2016 accessed 5/9/ Hawk C, Schneider M, Ferrance R, et al. Best Practice Recommendations for Chiropractic Care for Infants, Children, and Adolescents: Results of a consensus Process Journal of Manipulative and Physiological Therapeutics Volume 32, Number Wisconsin State Statute language regarding patient record requirements: Medicare LCD L33613 for Jurisdiction #6: Note: Login as registered user or Continue as a guest. Enter in the LCD/Policy Search field LCD L33613 for the details. Published 11/15/ CMS Guidelines for Evaluation and Management (E&M) Services. Published August Accessed at: Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/evalmgmt-serv-guide-ICN pdf Page 13 of 14

14 14. CPT Standard Edition. Copyright 2016 by the American Medical Association ICD-10-CM Professional for Physicians. Copyright 2017 Optum 360, LLC. All rights reserved HCPCS Level II codes. Copyright Optum360, LLC. All rights reserved ICD-10-CM Coding for Chiropractic. ChiroCode, Inc ChiroCode Deskbook. ChiroCode, 26th Edition. ChiroCode, Inc Papuga M and Cambron J. Foot orthotics for low back pain: The state of our understanding and recommendations for future research. Accessed May 15, 2017 Available at: Foot (Edinb) Mar; 26:53-7. doi: /j.foot Epub 2015 Dec 19 Aspirus Arise Review History: Implemented 01/01/17, 08/01/17, 07/01/18 Medical Policy 06/03/16, 06/16/17, 03/16/18 Committee Approval Reviewed 06/03/16, 06/16/17, 03/16/18 Revised 06/16/17, 03/16/18 Adopted 01/01/17 Approved by the Medical Director Page 14 of 14

Non-Pharmacological Interventions for Pain:! Chiropractic Manipulative Therapy!

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