Oxford Health Plans > Medical and Administrative Policies > Manipulative Therapy
Title of Policy

Manipulative Therapy

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies as well as SecureHorizons®/Oxford and Evercare.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.


Policy #: ALTERNATIVE 011.2 T2

Coverage Statement:

Policy is applicable to:
    Commercial plans
Note: For Medicare plans, refer to policy: Chiropractic Services for Medicare Plans.

Conditions of Coverage
Benefit Type Chiropractic1,2
General benefits package2
Referral Required
(Does not apply to non-gatekeeper products)
Yes1,2
Authorization (Precertification always required for inpatient admission) Yes1,2
Precertification with MD Review Yes1,2
Site(s) of Service
(If not listed, MD Review required)
Office2,Outpatient
Special Considerations 1Chiropractic services may require precertification through OptumHealth Care Solutions. Refer to Policy and Rationale and Treatment/Application Guidelines for details.
2Osteopathic manipulative treatment requires only a referral when performed in a physician's office setting.

Description of Service/Assessment/Background Information:

Manipulative treatment, also known as mobilization therapy or "adjustment," refers to manual therapy employed to soft or osseous tissues for therapeutic purposes. This term encompasses a wide variety of manual and mechanical interventions that may be high or low velocity; short or long lever; high or low amplitude; with or without recoil. Most often, manipulation is performed by applying a controlled force into a joint or joints of the spinal column to reduce or correct a specific derangement. Depending on the provider specialty, a joint derangement may be listed as a subluxation, vertebral subluxation complex, osteopathic lesion, somatic dysfunction or a mechanical dysfunction.

Craniosacral therapy is a noninvasive osteopathic technique that involves the therapist touching the patient to detect pulsations and rhythms of flow of cerebrospinal fluid (CSF). The therapist then gently works with the skull and spine, with the goal to effect release of potential restrictions to the flow of CSF, without the use of forceful physical manipulation. (Hayes, 2009)

Manipulative treatment has been proposed as either a singular intervention or a part of combined approach in the prevention of health-related disorders. (Axen 2009) Individuals may elect to receive care that may mitigate the development of a disorder i.e., primary prevention. Clinicians may provide manipulative therapy in an attempt to prevent new events (secondary prevention) or maintain patients at their best possible level once improvement has been achieved (tertiary prevention). This type of care is typically termed maintenance or custodial care. Other analogous terms include wellness, elective, preventive, and palliative care.

Clinical Evidence:

Manipulative therapy is most often performed on the spine and pelvis for musculoskeletal disorders. Its use has been investigated for a range of disorders.

Musculoskeletal Disorders
A 2011 Cochrane review by Rubinstein et al. (2011) evaluated 26 randomized controlled trials that assessed the effects of spinal manipulative therapy (SMT) in 6070 patients with chronic low-back pain. They concluded that SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy. However, it is less clear how it compares to no treatment or sham (placebo) treatment.

In a 2010 Cochrane review by Walker et al., 12 studies involving 2887 participants were evaluated to assess the various combinations of chiropractic care for low-back pain. The review showed that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain.

A 2010 Cochrane review of manipulation or mobilization for neck pain included 27 trials involving 1522 participants. The authors concluded cervical manipulation and mobilization may provide immediate- or short-term change; however, no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. (Gross, 2010) Further research is needed to establish whether cervical manipulation provides long-term relief.

A meta-analysis by Chou et al. (2007) evaluated non-pharmacologic therapies for acute and chronic low back pain and found that there is good evidence spinal manipulation is moderately effective for subacute and chronic low back pain; and fair evidence for small to moderate benefits for acute low back pain.

Dagenais et al. (2010) conducted a systematic review to evaluate spinal manipulation therapy for low back pain. Of 699 studies, 14 (n = 2,027 patients) were included for review. Spinal manipulation therapy was most commonly compared to physical modalities, education, medication, exercise, mobilization, or sham therapy. The authors found that the results from most studies suggest that 5 to 10 sessions of spinal manipulation therapy administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up.

A systematic review by Licciardone et al. (2005) of 6 osteopathic manipulative treatment (OMT) clinical trials were evaluated to assess the efficacy of OMT as a complementary treatment for low back pain. A total of 525 subjects with low back pain were randomized in the eligible trials. Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 - -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs. active treatment or placebo control and OMT vs. no treatment control. The authors concluded that OMT significantly reduces low back pain and the level of pain reduction was greater than expected from placebo effects alone. This review was limited by the various study designs such as the methodology, trial setting, subject characteristics, OMT and control treatment interventions, and pain measures.

Bronfort et al. (2010) conducted a comprehensive review of the effectiveness of manual therapies including manipulation and found spinal manipulation effective for the treatment of acute low back pain, acute/subacute neck pain, and chronic neck pain (when combined with exercise). However, the evidence for cervical manipulation/mobilization for tension type headaches as well as manipulation alone for coccydynia, sciatica and fibromyalgia was inconclusive.

A randomized controlled trial by Senna and Machaly (2011) investigated the effects of maintenance spinal manipulation therapy for chronic non-specific low back pain. Subjects were randomized into 3 groups and followed for 10 months. Group 1 (n=40) received sham manipulation during the first month and no treatment over the subsequent 9 months. Group 2 (n=27) received manipulation during the first month but no treatment during the following 9 months. Group 3 (n=26) received manipulation during the first month and 'maintenance' manipulation every 2 weeks for an additional 9 months. At the end of 10 months, 33 subjects declined follow-up. Five withdrew in the first phrase before treatment began. Of the remaining 88 subjects, 80 were evaluated at 4 months, 71 at 7 months and 60 at 10 months. Subjects in groups 2 and 3 experienced significantly lower pain and disability scores compared to the control group after the initial 1-month treatment period. At the end of 10 months, group 3 reported significantly lower pain and disability scores compared to Group 2. The authors concluded that spinal manipulation is an effective treatment for chronic non-specific low back pain. While Group 3 reported better outcomes, the basis of this improvement could not be determined as to whether it was the manipulation or the placebo effect of continued visits. The study is limited by lack of blinding, a 35% drop-out rate, and lack of long-term follow up to assess continued benefits of therapy.

Leaver et al. (2010) conducted a randomized controlled trial comparing manipulation with mobilization for recent onset of neck pain in 182 patients. Patients were randomly assigned to receive 4 treatments of either neck manipulation (n=91) or mobilization (n=91) over 2 weeks. Outcomes were measured by the number of days taken to recover from the episode of neck pain. Median days to recovery were 47 for the manipulation group and 43 days for the mobilization group. The authors concluded that manipulation was no more effective than mobilization in treating recent onset of neck pain.

A prospective, multicenter study by Rubinstein et al. (2007), evaluated 529 patients with neck pain to assess clinical outcomes and adverse events. Follow-up occurred at 3 and 12 months using questionnaires. Fifty-six percent of patients reported worsening of symptoms or onset of a new symptom during any one of the first 3 treatments. Only 5 patients (1%) reported to be much worse at 12 months. No serious adverse events were recorded during the study period. The authors concluded that while adverse events may be common, they are rarely severe in intensity. Most patients report recovery, particularly in the long term. Therefore, the benefits of chiropractic manipulative therapy for neck pain seem to outweigh the potential risks.

Non-musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, etc)
Bronfort et al. (2010) conducted a comprehensive review on the effectiveness of manual therapies including manipulation for various non-musculoskeletal disorders. While not all studies compare manipulation to sham manipulative treatment, the evidence for spinal manipulation did not support its effectiveness for asthma, dysmenorrhea, stage 1 hypertension, premenstrual syndrome, pneumonia, otitis media, enuresis, and infantile colic. Other systematic reviews have arrived at similar conclusions. (Ernst, 2001; Hondras, 2001; Hughes and Bolton, 2002; Mills et al., 2003; Hawk et al., 2007)

Prevention (primary, secondary, tertiary) for maintenance/custodial care
Martel et al. (2011) conducted a randomized controlled trial to compare the efficacy of preventive spinal manipulative therapy (SMT) to no treatment in 108 patients with non-specific chronic neck pain. The trial was divided into 2 phases. The first was the non-randomized, symptomatic phase during which all eligible participants received a short course of SMT. Ten patients dropped out of the study following the symptomatic phase. After completing the symptomatic phase, the remaining 98 participants were randomly assigned to 1 of 3 parallel groups (no treatment (n = 29), a SMT group (n = 36) or a SMT plus exercise group (n = 33)). The second preventive phase lasted 10 months. Outcomes were measured using visual analog scale (VAS), active cervical ranges of motion (cROM), the neck disability index (NDI) and the Bournemouth questionnaire (BQ). Patients were also asked to keep an exercise diary. Mean adherence to the home exercise program was 48.8%. In the preventive phase, all 3 groups showed outcomes scores similar to those obtain following the non-randomized, symptomatic phase. Overall spinal manipulation or spinal manipulation combined with exercises did not have any significant advantages when compared to the no treatment strategy. The authors found that preventive therapy was no more effective than no treatment at all for patients with non-specific chronic neck pain.

In a review, Aker and Martel (1996) concluded, "There is no scientifically valid research to support the assumption that spinal manipulation alone is a viable health promotion strategy." A more recent review has been published. (Leboeuf-Yde and Hestbaek, 2008) The authors reached several conclusions. "There is no evidence-based definition of maintenance care and the indications for and nature of its use remains to be clearly stated. It is likely that many chiropractors believe in the usefulness of maintenance care but it seems to be less well accepted by their patients. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown."

Axen at al. (2009) conducted a survey of 167 chiropractors to explore what factors chiropractors consider before recommending maintenance care to patients with low back pain (LBP). Based on the survey the authors concluded chiropractic treatment can prevent relapses of back pain; however, this is based on professional opinion and not patient outcomes.

Beyond a broad conceptual approach, there does not appear to be a consensus on the clinical application of maintenance/custodial care. "The indications for maintenance care and clear descriptions of preventive treatment for specific types of conditions are not found in the literature." (Axen 2008) With the exception of a pilot study, the general concepts of how to proceed over time with this type of patient are lacking.

Internal organ disorders
A detailed search of the medical peer-reviewed literature did not identify any clinical studies that evaluated manipulative therapy of internal organs such as the gallbladder, spleen, intestines, kidneys or lungs.

Temporomandibular Joint (TMJ) Disorders
The available published studies are primarily case reviews, uncontrolled or general review articles.

Three small randomized controlled trials evaluating temporomandibular joint disorders were identified. Monaco (2008) evaluated 28 subjects where kinesiographic tracings were used to assess the effects of osteopathic manipulative treatment (OMT) on the parameters of maximal mouth opening and movement velocities. Patient-centered outcomes of pain and function were not assessed. Clinical trials by Taylor et al. (1994) and Carmeli et al. (2001) were included in three systematic reviews.

A comprehensive review by Bronfort et al. (2010) found that the evidence for treating TMJ disorders with manipulation is inconclusive.

Two reviews by McNeely et al. (2006) and Medlicott and Harris (2206) concluded there is limited evidence for the use of manual therapy in the treatment of temporomandibular joint dysfunction.

There is insufficient evidence that manipulation of the TMJ will result in fewer symptoms or improve functionality.

Scoliosis
A systematic review by Romano and Negrini (2008) reviewed 73 papers, mainly case series, regarding manual therapy for idiopathic adolescent scoliosis. Only 3 papers were relevant to their study however none of the 3 satisfied all the required inclusion criteria because they were characterized by a combination of manual techniques and other therapeutic approaches. The authors found insufficient data to develop any conclusions on the efficacy of manual therapy for the treatment of adolescent idiopathic scoliosis.

Hasler et al. (2010) conducted a small (n=20) prospective controlled trial that investigated the effectiveness of osteopathic manual interventions (visceral and cranial manipulation) on trunk morphology in adolescent idiopathic scoliosis (AIS). The results showed no therapeutic effect on rib hump, lumbar prominence, plumb line, saggital profile and global spinal flexibility. The authors concluded they found no evidence to support osteopathic manual therapy for the treatment of mild AIS.

A prospective study by Glassman et al. (2010) evaluated the value of non-operative treatment, including manipulation, commonly used for adult scoliosis patients. There was no improvement in quality of life and disability measures observed over a minimum of 2-year follow-up within the subgroup of patients who elected to receive manipulative treatment. Similarly, there were no differences between groups including those who did not receive any treatment.

Extremity Disorders
A comprehensive review by Bronfort et al. (2010) evaluated the effectiveness of manual therapies including manipulation for a broad range of extremity disorders. The following had positive results: shoulder girdle pain and dysfunction, adhesive capsulitis, hip osteoarthritis, knee osteoarthritis, patello-femoral syndrome, and plantar fasciitis (when combined with exercise).

Shoulder
Ho et al. (2009) conducted a systematic review of 14 randomized controlled trials to evaluate the effectiveness of manual therapy (MT) techniques (including massage, joint mobilization and manipulation) for shoulder disorders. Results were analyzed within diagnostic subgroups (adhesive capsulitis (AC), shoulder impingement syndrome [SIS], non-specific shoulder pain/dysfunction) and a qualitative analysis using levels of evidence to define treatment effectiveness was applied. The authors concluded there was no clear evidence to suggest additional benefits of manual therapy to other interventions for shoulder impingement syndrome. The findings of the higher quality studies, however, favored manual therapy for pain reduction over exercise-alone and conventional physiotherapy-alone. Ranges of motion (ROM) outcomes were equivalent between groups receiving manual therapy and conventional physiotherapy. Studies that measured shoulder function favored the addition of manual therapy to exercises and were more effective than other physiotherapy procedures employed. In contrast, manual therapy was no more effective than other interventions in improving pain, range of motion, and function for the treatment of adhesive capsulitis. For non-specific shoulder pain/dysfunction, manual therapy was effective in reducing pain and short-term active range of motion, when compared to control groups and sham treatment. Perceived recovery favored manual therapy at both short-term and long-term follow-up.

Green et al. (2003) conducted a Cochrane review of 26 trials evaluating physiotherapy interventions for shoulder pain. Of the 26 trials included in the review, only 3 studies evaluated manual therapy and mobilization with and without exercise. The authors noted that combining mobilization with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease; however the same is not true for adhesive capsulitis.

Bergman et al. (2004) conducted a randomized, controlled trial of 150 patients with shoulder symptoms and dysfunction of the shoulder girdle. Patients were evenly allocated to receive manipulative therapy plus usual medical care (n=79) or usual medical care alone (n=71). Patients were prescribed oral analgesics or nonsteroidal anti-inflammatory drugs if necessary and if this was not effective, patients could receive up to 3 corticosteroid injections. Patients were followed for 52 weeks. Outcomes were measured by patient-perceived recovery, severity of the main complaint, shoulder pain, shoulder disability, and general health. During treatment (6 weeks), no significant differences were found between study groups. After completion of treatment (12 weeks), 43% of the intervention group and 21% of the control group reported full recovery. After 52 weeks, approximately the same difference in recovery rate (17 percentage points) was seen between groups. The authors concluded that manipulative therapy for the shoulder girdle in addition to usual medical care accelerates recovery of shoulder symptoms.

A prospective study by Mintken et al. (2010) utilized 5 prognostic factors associated with shoulder pain in 80 individuals to determine if cervical and thoracic spine manipulation would improve pain and disability. Participants underwent a standardized examination and then a series of thrust and non-thrust manipulations directed toward the cervicothoracic spine. Outcomes were measured using a 15-point Global Rating of Change (GROC) scale as well as outcomes from the prognostic variables. The GROC scale ranges from -7 ("a very great deal worse") to 0 ("about the same") to +7 ("a very great deal better"). Patients who rated their score as +4 or better were categorized as having a successful outcome. A total of 49 patients (61%) experienced a successful outcome. Mean Shoulder Pain and Disability Index (SPADI) scores decreased by more than 50% (from 38.1 to 18.4) in the successful group compared to 18% (from 37.9 to 30.4) in the non-successful group. Numeric pain rating scale (NPRS) scores also showed greater improvements in the successful group compared to the non-successful group. The participants' ability to flex the shoulder without pain improved significantly in both groups. The authors found that if 3 of the 5 variables were present, the chance of achieving a successful outcome improved from 61% to 89%. The study is limited by small sample size, lack of a control group and no long term follow-up.

Elbow, Wrist or Hand
Two systematic reviews encompassing a range of physiotherapies for lateral epicondylitis concluded the evidence is insufficient for most physiotherapy interventions including manipulation or mobilization. (Bisset et al., 2005; Smidt et al., 2003)

Two systematic reviews that included an assessment of extraspinal manipulation or mobilization for carpal tunnel syndrome reached disparate conclusions. A Cochrane review by O'Connor et al. (2003) of non-surgical treatment (other than steroid injection) for carpal tunnel syndrome concluded, "Current evidence shows significant short-term benefit from oral steroids, splinting, ultrasound, yoga and carpal bone mobilization... More trials are needed to compare treatments and ascertain the duration of benefit." Goodyear-Smith (2004) also authored a systematic review of nonsurgical treatment options for carpal tunnel syndrome. This review found, "The evidence does not support the use of nonsteroidal anti-inflammatory drugs, diuretics, pyridoxine (vitamin B6), chiropractic [manipulative] treatment, or magnet treatment."

In a comparative study by Struijs et al. (2003), 31 patients with lateral epicondylitis were randomly assigned to receive either manipulation of the wrist (n=15) or ultrasound, friction massage, and muscle stretching and strengthening exercises (n=16). Follow-up was at 3 and 6 weeks with 3 patients electing to drop out of the study. After 3 and 6 weeks of intervention, no differences in mean improvement in range of motion was found within or between the groups. The authors were unable to definitively conclude the effectiveness of manipulation and recommend further research with randomization, and longer-term follow-up to further evaluate the use of manipulation for lateral epicondylitis.

Hip osteoarthritis
A randomized clinical trial by Hoeksma et al. (2004) evaluated 109 patients with osteoarthritis of the hip to compare the effectiveness of a manual therapy (n=56) with exercise therapy (n=53) with a mean age of 72 years. The manual therapy group received therapy including manipulations and vigorous stretching while the control group received standard exercise therapy, which may have included stretching but did not include manipulation. The treatment period was 5 weeks (9 sessions). Outcomes were measured by general perceived improvement after treatment, level of pain, hip function, walking speed, range of motion, and quality of life. No major differences were found on baseline characteristics between groups. Success rates (primary outcome) after 5 weeks were 81% in the manual therapy group and 50% in the exercise group. Furthermore, patients in the manual therapy group had significantly better outcomes on pain, stiffness, hip function, and range of motion with results maintained after 29 weeks. The authors concluded that manual therapy is superior to exercise therapy for patients with OA of the hip.

Knee osteoarthritis
Licciardone et al. (2004) conducted a randomized controlled trial of 30 patients who recently underwent surgery for knee osteoarthritis to evaluate the efficacy of osteopathic manipulative treatment (OMT) in the hospital setting. Patients were randomly assigned to receive either OMT or sham treatment. Patients receiving OMT for knee osteoarthritis had longer length of stays, decrease efficiency in rehabilitation and vitality. The authors concluded that osteopathic manipulative treatment does not appear to be efficacious in this hospital rehabilitation population.

Ankle and Foot
Cleland et al. (2009) conducted a multicenter randomized clinical trial of 60 patients with plantar heel pain to compare the effectiveness of electrophysical agents and exercise (EPAX) which included iontophoresis with dexamethasone and stretching of the gastrocnemius muscle and/or plantar fascia or a manual physical therapy and exercise (MTEX) which included aggressive soft tissue mobilization directed at the triceps surae and the insertion of the plantar fascia at the medial calcaneal tubercle. Patients were equally split between the control and treatment groups and followed for 6 months. Outcomes were measured utilizing a number of patient self-report questionnaires, including the Lower Extremity Functional Scale (LEFS), the Foot and Ankle Ability Measure (FAAM), and the Numeric Pain Rating Scale (NPRS). The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance (ANOVA). Both groups demonstrated a significant improvement over time; however, the patients receiving in the MTEX group experienced greater clinical benefits in terms of function and pain than the patients in the EPAX group.

Three randomized controlled trials (Eisenhart et al., 2003; Green et al., 2001; Lopez-Rodriquez et al., 2007) evaluated the effects of manipulation on acute ankle sprain primarily in athletes. Two studies (Eisenhart et al., 2003; Lopez-Rodriquez et al., 2007), limited treatment to a single session while one study (Green et al., 2001) evaluated adjustments over 14 days (6 sessions).

A randomized trial by du Plessis et al. (2011) compared manual and manipulative therapy (MMT) with standard care of a night splint(s) for symptomatic mild to moderate hallux abducto valgus (HAV). Thirty patients were equally assigned to each group. The control group used a night splint(s) while the experimental group (MMT) received 4 MMT 4 treatments over a 2-week period. Outcomes were measured with visual analogue scale, foot function index and hallux dorsiflexion. Outcome measure scores in the control group (night splint) regressed between the 1-week follow-up and 1-month follow-up when patients did not use the night splint, while the scores in the experimental group (MMT) were sustained up to the 1-month follow-up. The authors concluded that a structured protocol of manual and manipulative therapy is equivalent to standard care of a night splint(s) for symptomatic mild to moderate HAV in the short term.

A pilot study by Pellow and Brantingham (2001) evaluated the use of manipulation in 30 patients with ankle sprain. Patients were equally divided to receive either an adjustment or ultrasound treatment over 4 weeks. While both groups showed improvement, the authors found that the adjustment group had greater reduction in pain, increased ankle range of motion, and ankle function.

Craniosacral therapy
There was some evidence from 3 small, randomized studies that craniosacral therapy may have a positive effect on tension-type headache pain, infantile colic, and asthma. However, these studies all had significant limitations, including lack of blinding, small sample size, use of largely qualitative or subjective outcome measures, and in 1 study a high dropout rate. The overall level of evidence regarding craniosacral therapy for these indications is weak, and no conclusions regarding the efficacy of this technique can be made. (Hayes, 2009)

Professional Societies
The American Osteopathic Association (AOA): A 2010 guideline recommends osteopathic manipulation be utilized to treat patients with musculoskeletal causes of low back pain such as diagnoses of somatic dysfunctions related to the low back pain. Osteopathic manipulative treatment for somatic dysfunction is utilized only after other potential causes of low back pain are ruled out or considered improbable by the treating physician (ie, vertebral fracture; vertebral joint dislocation; muscle tears or lacerations; spinal or vertebral joint ligament rupture; inflammation of intervertebral disks, spinal zygapophyseal facets joints, muscles or fascia; skin lacerations; sacroiliitis; ankylosing spondylitis; masses in or from the low back structures; or organic [visceral] disease referring pain to the back or causing low back muscle spasms).

American College of Physicians and the American Pain Society (ACP/APS): Clinical guidelines published jointly by ACP and APS for the diagnosis and treatment of low back pain recommend spinal manipulation for patients who do not improve with self-care options along with a number of other nonpharmacological therapies, (Chou et al., 2007).

U.S. Food and Drug Administration (FDA):

A manipulative service is a procedure and therefore not subject to FDA regulation.

Policy and Rationale:

  1. Chiropractic Services

    Oxford has delegated certain administrative services to OptumHealth Care Solutions ("OHCS"). OHCS is responsible for the following tasks related to administration of chiropractic benefits:

    • appeals (1st level administrative and 1st level clinical)
    • claim payment
    • network maintenance
    • quality management complaints
    • utilization management (both in- and out-of-network)

    For additional information regarding the clinical support and utilization management services provided by OHCS, including clinical review criteria, visit: https://www.myoptumhealthphysicalhealth.com/CPwelcome.html.

    Oxford has retained responsibility for 2nd level internal Member appeals, external Member appeals and regulatory inquiries.

    Refer to the Treatment/Application Guidelines section of this policy for additional information regarding the management of chiropractic benefits.

  2. Osteopathic Manipulative Treatment

    Osteopathic manipulative treatment is not subject to delegation, and coverage for this service is managed by Oxford. Refer to the Treatment/Application Guidelines section of this policy for additional information.

Treatment/Application Guidelines:

Manipulative therapy is considered to be medically necessary when used in the treatment of musculoskeletal disorders.

Manipulative therapy is not considered to be medically necessary for treatment of:

  • non-musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, etc)
  • prevention/maintenance/custodial care
  • internal organ disorders (e.g., gallbladder, spleen, intestinal, kidney, or lung disorders)
  • temporomandibular joint (TMJ) disorder
  • scoliosis correction
  • craniosacral therapy (cranial manipulation/upledger technique)
  • manipulative services that utilize nonstandard techniques such as applied kinesiology technique, NUCCA, network and neural organizational technique

The role of manipulation for the above has not been established in scientific literature. A beneficial impact on health outcomes, e.g., improved physical function, durable pain relief, has not been established.

Additional information to support medical necessity review where applicable

Manipulative therapy is not recommended when ANY of the following apply:

  1. The patient's condition has returned to the pre-symptom state.
  2. Little or no improvement is demonstrated within 30 days of the initial visit despite modification of the treatment plan.
  3. Concurrent manipulative therapy, for the same or similar condition, provided by another health professional whether or not the healthcare professional is in the same professional discipline.

This policy does not address manipulation under anesthesia; refer to policy: Manipulation Under Anesthesia.

  1. Chiropractic Services

    • Network Providers
      All in-network chiropractic services, including the initial visit, require submission of the Patient Summary Form and Patient Health Questionnaire within 10 days of the date of service for payment. Network providers are contractually required to submit this documentation within the applicable timeframe. In the absence of timely submission, OptumHealth Care Solutions will not perform a review and services will not be reimbursed. Members may not be balance billed in this scenario.

      For clinical determinations that support treatment, a specific number of chiropractic manipulative treatment (CMT) codes, adjunctive services and/or date range will be established. The provider and Member will receive written notification of approved services and applicable timeframes. Requests for review of additional/subsequent treatment will require submission of a current Patient Summary Form and Patient Health Questionnaire.

    • Non-Network Providers
      All out-of-network chiropractic services will be reviewed for medical necessity and reimbursement based on the Member's benefit coverage and medical appropriateness.

      Members (and non-network providers, with Member's consent) have the option to submit the Patient Summary Form and Patient Health Questionnaire prior to delivery of chiropractic care. This is called the Voluntary Prior Approval ("VPA") process. For clinical determinations that support treatment, a specific number of chiropractic manipulative treatment (CMT) codes, adjunctive services and/or date range will be established. The provider and Member will receive written notification of approved services and applicable timeframes. Requests for pre-service review of additional/subsequent treatment will require submission of a current Patient Summary Form and Patient Health Questionnaire.

      Services rendered/billed but not reviewed via the VPA process will be retrospectively reviewed for coverage based on benefit availability and medical appropriateness. Members are responsible for any expenses beyond those which are determined reimbursable based on medical necessity and availability of benefits as detailed in the certificate of coverage, contract and/or benefit plan documentation.

  2. Additional Services Rendered by a Doctor of Chiropractic (DC)

    • Laboratory Services: Oxford will provide coverage for laboratory services, subject to benefit availability, refer to policy: Oxford's In-Office Laboratory Testing and Procedures List and any other applicable policies.

    • Diagnostic Imaging Services: The purpose of radiographic examination is to assist the practitioner in the diagnosis of pathology. Studies are performed to confirm or contribute to the clinical picture and should be taken only when medically necessary. In addition, chiropractors are privileged to perform only certain radiologic procedures. For additional information, refer to policy: Oxford's Radiology Privileging List.

    • Electrodiagnostic Services: Doctors of Chiropractic (DCs) are accountable to demonstrate clinical competency in the performance and interpretation of electrophysiologic studies. Unless otherwise specified by specific state statute or regulations, competency must be demonstrated by the successful completion of a certificate program sponsored by a chiropractic college accredited by the Council of Chiropractic Education or certification from an accredited educational institution recognized by the state in which services are to be performed. A copy of the certificate must be on file with OptumHealth Care Solutions for consideration of benefit coverage criteria.

  3. Osteopathic Manipulative Treatment

    Oxford will allow separate reimbursement for osteopathic manipulation when billed submitted alone or with:

    • a new patient evaluation/management (E/M) code; or
    • an established patient evaluation/management (E/M) office visit and modifier -25 has been appended to indicate that a significant and separately identifiable E/M service has been provided in addition to osteopathic manipulation

Payment Guidelines:

Chiropractic Services
OptumHealth Care Solutions will reimburse chiropractic providers for the following CPT/HCPCS codes in accordance with the provider's scope of practice, the terms of this policy, and the Member's available benefits. Chiropractic services include, but are NOT limited to, the procedure codes listed below.

Code Description
72010 Radiologic examination, spine, entire, survey study, anteroposterior and lateral
72040 Radiologic examination, spine, cervical; two or three views
72069 Radiologic examination, spine, thoracolumbar, standing (scoliosis)
72070 Radiologic examination, spine; thoracic, two views
72080 Radiologic examination, spine; thoracolumbar, two views
72100 Radiologic examination, spine, lumbosacral; two or three views
95900 Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study
95903 Nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study
95904 Nerve conduction, amplitude and latency/velocity study, each nerve; sensory
97012 Application of a modality to one or more areas; traction, mechanical
97016 Application of a modality to one or more areas; vasopneumatic devices
97018 Application of a modality to one or more areas; paraffin bath
97022 Application of a modality to one or more areas; whirlpool
97024 Application of a modality to one or more areas; diathermy (eg, microwave)
97026 Application of a modality to one or more areas; infrared
97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes
97035 Application of a modality to one or more areas; ultrasound, each 15 minutes
97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
97116 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)
97124 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions
98941 Chiropractic manipulative treatment (CMT); spinal, three to four regions
98942 Chiropractic manipulative treatment (CMT); spinal, five regions
98943 Chiropractic manipulative treatment (CMT); extraspinal, one or more regions
99201 Office or other outpatient visit for the evaluation and management of a new patient (Level I)
99202 Office or other outpatient visit for the evaluation and management of a new patient (Level II)
99203 Office or other outpatient visit for the evaluation and management of a new patient (Level III)
99211 Office or other outpatient visit for the evaluation and management of an established patient (Level I)
99212 Office or other outpatient visit for the evaluation and management of an established patient (Level II)
99213 Office or other outpatient visit for the evaluation and management of an established patient (Level III)
99214 Office or other outpatient visit for the evaluation and management of an established patient (Level IV)
G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care

Osteopathic Manipulative Treatment

Code Description
98925 Osteopathic manipulative treatment (OMT); one to two body regions involved
98926 Osteopathic manipulative treatment (OMT); three to four body regions involved
98927 Osteopathic manipulative treatment (OMT); five to six body regions involved
98928 Osteopathic manipulative treatment (OMT); seven to eight body regions involved
98929 Osteopathic manipulative treatment (OMT); nine to ten body regions involved

The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by the UnitedHealthcare Medical Technology Assessment Committee. [2011T0541B]

References:
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Effective Date: June 1, 2011 through November 30, 2011