POLICY: DOCUMENTATION – MEDICAL NECESSITY
Policy Number: MED – 6012 / Page(s): 1 of 2
Approved by: / Effective Date:

PURPOSE: Medicare considers chiropractic treatment a covered expense when ALL of the following criteria are met:

  1. The patient 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.
  2. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam.

PROCEDURE: To be reasonable and necessary, items and services must have been established safe and effective. That is:

  1. Consistent with symptoms or diagnosis of the illness under treatment;
  2. Necessary and consistent with the generally accepted professional medical standards (i.e., not experimental or investigational);
  3. Not furnished primarily for the convenience of the patient, the attending physician, or other medical professionals, or family members; and
  4. Furnished at the most appropriate level, which can be provided safely and effectively to the patient.

The following guidelines will be utilized to determine when an AT modifier should be placed on the claim to signify that the treatment was considered “active care.” The following conditions would fall under that category and be reimbursable by Medicare:

  1. Acute subluxation
  2. New injury identified by physical exam or x-ray.
  3. Result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of the patient’s condition.
  4. Chronic subluxation
  5. Condition is not expected to significantly improve or be resolved with further treatment but where continued therapy can be expected to result in some functional improvement.
  6. Once the clinical status has remained stable for a given condition, without expectation of additional objective improvements, further manipulative treatment is considered maintenance therapy and is not covered.

Maintenance therapy is not considered to be medically necessary under the Medicare program and is defined as follows:

  1. Treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life.
  2. Therapy performed to maintain or prevent deterioration of a chronic condition.
  3. When further clinical improvement cannot be reasonably expected from continuous ongoing care.

Following the release of a patient OR once a patient’s care has been deemed to be maintenance in nature, the following situations may warrant chiropractic services to be considered medically necessary again:

  1. New Injury – a recent initial injury that has never been treated in the past identified by x-ray or physical exam as specified above.
  1. Re-injury/Recurrence – return of symptom of a previously treated condition that has been asymptomatic for a period of time, e.g. 30 or more days.
  1. Exacerbation – a temporary marked deterioration of the patient’s condition due to a flare up of:
  2. A condition being treated, in which case additional treatment may be allowed but would not necessitate a whole new course of treatment.
  3. A chronic condition (after having achieved maximum therapeutic benefit and stabilized functional status for a reasonable period of time) where the patient experiences a marked increase in symptoms from baseline. This may warrant an initiation of a new course of treatment.
  4. Exacerbation must be documented in the patient’s clinical record; including the date of occurrence, nature of the onset, or other pertinent factors that will support the reasonableness and necessity of treatment.