Subject:
Chiropractic Review Policy
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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This represents the guiding principles for review of chiropractic benefits.
A member must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function. Strains, vertebral subluxations, nerve pains and functional mechanical disabilities of the spine and spine-related structures (extremities with clinical relationship to the diagnosis in which manipulation of these areas are performed in conjunction with spinal manipulation) are considered to provide therapeutic grounds for chiropractic manipulative treatment.
Policy:
(INFORMATIONAL NOTE: Chiropractic service is subject to specific member contract limitations. This policy gives guidance on how chiropractic benefits will be determined based on the terms and conditions in the member’s contract. If there is a discrepancy between this policy and a member’s contract, the contract will govern.
NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
1. Utilization review is an objective evaluation, by practitioners of the same discipline, where the clinical information or treatment records maintained by the attending chiropractor or the chiropractor of record, are assessed and evaluated to determine the appropriateness of care provided to the member relative to the clinically supported condition/diagnoses as well as the current clinical status of the member. The determination of the appropriateness of care/member status is based on the clinical evidence contained within the medical documents maintained by the attending chiropractor or chiropractor of record as well as an application of accepted guideline factors qualifying maximum medical improvement. Circumstances may arise where the performance of an Independent Chiropractic Examination (I.C.E.) may be used as an adjunct to the utilization review process to aid or enhance in the objective assessment of the current clinical status and determination of maximum medical improvement.
2. Phases of Active Care in Chiropractic Treatment
- Phase One - Treatment provided is to alleviate pain and is directed to limit the extent of the injury or condition, reduce signs and symptoms of inflammation, and to minimize functional disability. The short-term use of adjunctive therapeutic modalities/procedures may be appropriate in addition to manipulative procedures. If significant improvement in the patient's pain and functional ability is not achieved in the first two weeks of care, alternative treatment options should be explored.
- Phase Two - Treatment provided is directed to focus on improving pain-free ranges of motion and restoration of function to the fullest extent possible, promoting structural integrity and avoid de-conditioning. Frequency of treatment and use of therapeutic modalities typically decreases according to member progress and care should transition from passive to active treatments.
- Phase Three - Treatment provided is directed to focus on promoting the restoration of strength, endurance and performance of activities necessary for daily living.
* Duration and frequency of treatment is variable and is based on the severity and type of the injury/condition, functional limitations, as well as the resolution of the condition or attainment of maximum medical improvement.
[INFORMATIONAL NOTE: The phases of active care in Chiropratic treatment can also be categorized as follows:
1. Relief Care - patient management is directed towards reducing symptoms and/or improving function to a tolerable level.
2. Therapeutic Care - this level of care should enable a patient to perform most normal daily activities without frequent exacerbation of their condition.
3. Rehabilitative Care - the goal of this phase is to return the patient to pre-clinical status or Maximal Medical Improvement.]
3. Maximum Medical Improvement (MMI)
When the member returns to pre-injury status or fails to improve beyond a certain level of symptomatology or functional disability and further significant improvement from ongoing treatment is not objectively demonstrated, the member is at clinical plateau. At this point, further treatment would not result in a meaningful clinical progression and would not be considered medically necessary.
Meeting one of the following criteria would reasonably indicate a member is at MMI:
A. If the member’s condition is asymptomatic and/or has reached pre-clinical status.
B. Chiropractic, orthopedic, neurologic and range of motion tests performed by the attending chiropractic physician indicate attainment of functional ranges and abilities necessary for usual activities of daily living.
C. When the member fails to make significant functional improvement over a normal clinically expected time period for the member's condition and/or subjective symptoms and objective findings assessed on re-examinations remain do not meaningfully change.
4. Maintenance Care
This type of care is considered the continuation of therapeutic treatment once the member has reached a clinical plateau or maximum improvement. It is typically rendered on a regular basis to help maintain optimal body function and usually when there is little or no active symptomatology or the symptoms have become stationary. This treatment usually is for a chronic condition or after completion of therapeutic care. Continued treatment after a member has reached a clinical plateau or MMI, resolution and/or stabilization of a condition would constitute maintenance type care. This type of treatment is not a covered benefit.
5. Supportive Care
Periodic trials of withdrawal of care fail to sustain previous therapeutic gains that would otherwise progressively deteriorate and appropriate alternative forms of treatment including home-based self-treatment have been considered and/or attempted. Typically, the member would go at least 1-2 months or more without in-office treatment and upon re-examination, have objective and subjective clinical findings that when compared to previous examination findings indicate significant deterioration of clinical status. There must be objective evidence of a chronic or permanent condition and ancillary diagnostic tests must correlate with clinical examination findings.
Supportive care would be inappropriate if it interfered with other appropriate primary care, or, when the risk of supportive care outweighs its benefits; i.e., physician dependence, somatization, illness behavior secondary gain.
When supportive care is appropriate, it typically is rendered at a reduced frequency of visits and is not rendered on a pre-scheduled or routine basis but in response to symptomatic exacerbations.
6. Chiropractic Manipulative Therapy
The practice of chiropractic is that member health care discipline whose methodology is the adjustment and/or manipulation of the articulations of the spine and spine-related structures (extremities with clinical relationship to the diagnosis and in conjunction with spinal manipulation).
Chiropractic Manipulative Therapy (CMT) is a form of manual treatment to influence joint and neurophysiological function. This treatment may be accomplished using a variety of techniques.
For purposes of CMT, the five spinal regions referred to are; cervical (includes atlanto-occipital joint), thoracic (includes costovertebral and costotransverse joints), lumbar, sacral and pelvic (sacroiliac joint). CMT of extremities is defined as a separate region (extraspinal).
Clinical justification for administering CMT and specific documentation protocols should be based on the chiropractor's clinical judgement. However, documentation of clinical justification for administering CMT to any given area should be recorded in the member chart on the day of the visit and include the following:
A. a record of the member’s subjective complaint;
B. objective physical findings to support manipulation in a region or segment;
C. assessment of change in member condition, as appropriate;
D. a record of specific segments manipulated.
Clinical documentation must substantiate the need for adjusting specific regions of the spine and its related structures (extremities). This must correlate with the member's complaints and health assessment, as well as the member history, clinical examination, and the diagnoses.
All records must be legible and understandable. Uniform chiropractic language used within the profession should be utilized in documenting care and treatment. Non-standard abbreviations and indexes should be defined.
7. Evaluation and Management (E&M) Services
According to CPT coding guidelines, chiropractic manipulative therapy (CMT) codes include a pre-manipulation patient assessment. An E&M service may be reported in addition to CMT if the member's condition requires a significant separately identifiable E&M service that is above and beyond the usual preservice and postservice work associated with the CMT.
8. Physical Medicine Modalities
A. In addition to CMT, physical medicine modalities/procedures both passive and active may be utilized as adjunctive treatments.
B. Passive modalities are most effective during the acute phase (Phase 1) of treatment, as they are typically directed at reducing pain and swelling. In some instances,they may also be used during the acute phase of an exacerbation of a chronic condition.
C. Treatment plans for patients who are at risk for developing chronic conditions should de-emphasize passive care and refocus on active care approaches.
D. As swelling and inflammation are reduced, the need for stabilization and support is replaced by the need to increase range of motion and restore function.
E. Active procedures focus on patients' active participation in their exercise programs. Progressive resistive exercises are considered active procedures.
F. Clinical documentation must substantiate the need for active care procedures. This must correlate with the member's complaints and health assessment, as well as the patient history, clinical examination, and the diagnoses.
Medicare Coverage:
Any service by a Chiropractor other than manual manipulation for the treatment of subluxation of the spine is noncovered.
There is no National Coverage Determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued an LCD Chiropractic Services L35424 AND a Local Coverage Article: Chiropractic Services (A52987). Any service by a Chiropractor other than manual manipulation for the treatment of subluxation of the spine is noncovered.
Excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation of the spine. The following are examples (not an all-inclusive list) of services excluded from Medicare coverage when performed by a chiropractor; the member is responsible for payment.
- Laboratory tests
- X-rays
- Office visits (history and physicals)
- Physiotherapy
- Traction
- Supplies
- Injections
- Drugs
- EKGs or any diagnostic study
- Acupuncture
- Orthopedic devices
- Nutritional supplements/counseling
- Any service ordered by the chiropractor
Please refer to LCD Chiropractic Services L35424 for additional information. Available to be accessed at CMS National Coverage Determinations (LCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/lcd-alphabetical-index.aspx?DocType=All.
Please refer to Local Coverage Article: Chiropractic Services (A52987). Available to be accessed at CMS Articles Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/article-alphabetical-index.aspx?DocType=All
For Medicare Advantage Products ONLY: The following number of chiropractic spinal manipulation services (CPT codes 98940, 98941 and 98941) is considered reasonable and necessary if the medical record supports the service regardless of the nature of the visit (i.e., acute injury, acute exacerbation):
Twelve (12) chiropractic manipulation treatments per calendar month. AND,
Thirty (30) chiropractic manipulation treatments per calendar year.
For MAPPO-SHBP Product, Chiropractic services are limited to 30 visits total per calendar year inclusive of in-network and out of network visits.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE-SNP Coverage:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Chiropractic Review Policy
References:
1. Medical Review Benchmarks (American Chiropractic Association).
2. Guidelines for Chiropractic Quality Assurance and Practice Parameters; Proceedings of the Mercy Center Consensus Conference.
3. Chiropractic Physicians Guide to Clinical Malpractice; The National Chiropractic Mutual Insurance Company.
4. Chiropractic Standards of Practice and Quality of Care; Herbert J. Veer, D.C.
5. Procedural/Utilization Facts; Richard Olson, D.C.
6. Chiropractic Malpractice; Peter J. Modde, D.C.
7. New Jersey Chiropractic Standards, ratified no revisions 2002.
8. Chiropractic Risk Management Guide; C. Jacob Ladenheim, D.C.
9. Chiropractic Malpractice and the Role of the Expert Witness; Alan H. Bragman, D.C.
10. ChiroCode DeskBook; 1999 Edition.
11. Diagnosis to Treatment Planner; 1999 Edition.
12. Acute Low Back Problems in Adults, Assessment and Treatment; U.S. Department of Health and Human Services.
13. Chiropractic Treatment Guidelines; Ohio State Chiropractic Association.
14. Chiropractic Treatment and Reference Guidelines; Montana Chiropractic Association.
15. Guidelines for Chiropractic Care in Montana; Montana Chiropractic Association.
16. A Guide to Peer Review in Pennsylvania; Pennsylvania Chiropractic Association.
17. Medical-Legal Issues in Chiropractic; Foreman, Stahl & Sportelli.
18. Instant Access to Chiropractic Guidelines & Protocols; Huff & Brady.
19. The New Jersey State Board of Chiropractic Examiners, Rules & Regulations.
20. Hurwitz EL, Morgenstern H, Harber P, et al. Second Prize: The effectiveness of physical modalities among patients with low back pain randomized to chiropractic care: Findings from the UCLA low back pain study. J Manipulative Physiol Ther. 2002;25(1):10-20.
21. Hurwitz EL, Morgenstern H, Kominski GF, et al. A randomized trial of chiropractic and medical care for patients with low back pain: Eighteen-month follow-up outcomes from the UCLA low back pain study. Spine. 2006;31(6):611-622.
22. Haas M, Groupp E, Kraemer DF. Dose-response for chiropractic care of chronic low back pain. Spine J. 2004;4(5):574-583.
23. Hsieh CY, Adams AH, Tobis J, et al. Effectiveness of four conservative treatments for subacute low back pain: A randomized clinical trial. Spine. 2002;27(11):1142-1148.
24. Shekelle P, Vernon H. Spinal manipulation in the treatment of musculoskeletal pain. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on October 5, 2018.)
25. Knight CL, Deyo RA, Staiger TO, Wipf, JE. Treatment of acute low back pain. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on October 5, 2018.)
26. Chou R. Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on October 5, 2018.)
27. Isaac Z. Treatment of neck pain. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on October 5, 2018.)
28. Shekelle P. Spinal manipulation in the treatment of musculoskeletal pain. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on October 1, 2019.)
29. Knight CL, Deyo RA, Staiger TO, Wipf JE. Treatment of acute low back pain. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on October 1, 2019.)
30. Chou R. Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on October 1, 2019.)
31. Isaac Z. Treatment of neck pain. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on October 1, 2019.)
32. Shekelle P, Tang B. Spinal manipulation in the treatment of musculoskeletal pain. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on August 19, 2020.)
33. Knight CL, Deyo RA, Staiger TO, Wipf JE. Treatment of acute low back pain. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on August 19, 2020.)
34. Chou R. Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on August 19, 2020.)
35. Isaac Z. Management of non-radicular neck pain in adults. In: UpToDate, Atlas SJ, Kunins L (Eds), UpToDate, Waltham, MA. (Accessed on August 19, 2020.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
97010
97012
97014
97016
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97530
98940
98941
98942
98943
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
HCPCS
* CPT copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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