Humana Commercial Clinical Policy

Humana Chiropractic Care Form


Effective Date

07/27/2023

Last Reviewed

NA

Original Document

  Reference



Description

Chiropractic is a health care discipline that focuses on the relationship between the body’s (primarily the spine) structure and function. Chiropractic care is provided by a Doctor of Chiropractic (DC), also known as a chiropractor or a chiropractic physician whose focus is diagnosis and treatment of mechanical disorders of the spine and musculoskeletal system. The goal of chiropractic treatment is to affect the nervous system and improve health. Chiropractic care is based on the theory that a spinal joint dysfunction can interfere with the nervous system and impact the overall health of an individual.

Chiropractors use a type of hands on therapy known as manipulation (or adjustment) as their primary treatment. The manipulations are most commonly of the spine, though they may also give adjustments to extremities and other joints.

Chiropractic Care

Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0384-020

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Based upon state specific license and scope of practice, they may also utilize other treatment modalities such as cold/heat therapy, electrical stimulation, ultrasound and therapeutic exercise instruction.

For information regarding coverage determination/limitations not addressed in this medical coverage policy, please refer to the following:

  • Braces, splints and supports
  • Orthotics
  • Cold therapy devices/heating
  • Cold Therapy Devices/Heating
  • devices/combination heat and
  • Devices/Combined Heat and Cold Therapy
  • Devices
  • Dynamic spinal visualization
  • Videofluoroscopy, Dynamic MRI for
  • Musculoskeletal Indications
  • Low level laser therapy or high
  • Low Level Laser and High Power Laser
  • power laser therapy
  • Therapy
  • Manipulation under anesthesia
  • Manipulation Under Anesthesia
  • Monochromatic infrared energy (MIRE) therapy
  • Code Compendium (Wound Care)
  • Portable (home) ultrasound devices
  • Durable Medical Equipment
  • Surface EMG
  • Nerve Conduction Testing, Somatosensory and Visual Evoked Potentials, Surface

Coverage Determination

Please refer to specific certificate language to determine benefit availability and the terms and conditions of coverage for chiropractic care (e.g., spinal manipulations/adjustments).

Any state mandates for chiropractic care take precedence over this medical coverage policy.

Humana members may be eligible under the Plan for chiropractic care when the following general criteria are met:

  • Chiropractic care must be performed by a licensed healthcare professional acting

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Services provided must be of the complexity and nature to require that they are performed by a licensed chiropractor or provided under their direct supervision by a licensed ancillary person according to state licensure laws; AND
  • Services must be provided in accordance with an ongoing, written plan of care that is in accordance with applicable federal and state laws and regulations and nationally accepted professional standards of care; AND
    • The plan of care should be of such sufficient detail and include appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment. This information should include at least the following:
      • Initial evaluation/assessment/history and physical; AND
      • Long and short term goals that are specific, quantifiable (measurable) and objective; AND
      • Specific chiropractic techniques, treatments or exercises to be used along with identification of spinal and/or body region treated; AND
      • Reasonable estimate as to the time when these goals will be achieved; AND
      • Frequency and duration of the treatments provided must be reasonable and customary under the generally accepted standards of practice for chiropractic care; AND
  • Individual must have a musculoskeletal or neuromusculoskeletal condition, creating a functional impairment, necessitating an appropriate, medically necessary evaluation and treatment services; AND
  • Services provided must be clinically indicated, medically necessary, in accordance with each subscriber certificate and appropriately documented in the medical record; AND
  • There must be a reasonable expectation of recovery or improvement in function to support the onset and continuation of a therapeutic level care plan; AND
  • Services should be reflective of an acute care model and episodic in nature; ongoing care after the condition has stabilized or the individual's condition has reached a clinical plateau, called maximum medical improvement (MMI), may not qualify as medically necessary covered services

Cost of supplies (e.g., theraband, electrodes) used in furnishing chiropractic care is considered integral to the general services with which they are associated and not separately reimbursable.

Humana members may be eligible under the Plan for fluidized therapy (fluidotherapy) if the above general criteria are met, in addition to the following:

  • Maximum duration of fluidized therapy treatment is 4 weeks; AND
  • Utilized as an alternative to other heat therapy modalities in the treatment of acute or subacute traumatic or nontraumatic musculoskeletal disorders of the extremities; AND
  • The following contraindications to fluidized therapy are not present:
    • Severe circulatory obstruction disorders (e.g., arterial, lymphatic or venous disorders); OR
    • Systemic infectious diseases (e.g., diabetes mellitus, hypertension, influenza)

Note: The criteria for chiropractic care (manipulation) are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members.

Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for chiropractic care for any indications, treatment techniques or modalities other than those listed above

  • Adjustments/manipulations in an asymptomatic individual or for those without an identifiable clinical condition; OR
  • Adjustments/manipulations in an individual whose condition is neither regressing nor improving; OR
  • Augmented soft tissue mobilization (ASTYM or ASTM technique); OR
  • Back school and other return-to-work/reintegration or vocational programs including work hardening (may be excluded by certificate); OR
  • Duplicative services for the same clinical condition or problem, such as chiropractic care and habilitative or rehabilitative physical or occupational therapy. If both therapies are provided, the treatment programs must be separately determined and part of specific, separate written treatment plans; the therapies must provide significantly different treatments and not be seen as generally duplicating each other; OR
  • Graston technique; OR
  • Internal manipulation (transvaginal, transrectal) for conditions including, but may not be limited to: chronic pelvic pain, vulvodynia, pudendal neuralgia or interstitial cystitis; OR
  • Kinesio taping; OR
  • Lifestyle enhancement care, such as exercises to promote overall fitness, flexibility, provide diversion or motivation; OR
  • Maintenance care (may be excluded by certificate) consists of activities that generally are intended to preserve the individual’s present level of function and/or prevent regression of that level of function including, but may not be limited to, the following:
    • Maintenance begins when the therapeutic goals of the treatment program are achieved or when no further significant progress is made or reasonably seen as occurring (e.g., transition to a home exercise program [HEP]); AND
    • Individual has achieved generally accepted normal levels of function and/or muscle strength and has reached a plateau (generally a period of 4 weeks or less, depending on the specific condition and/or individual situation); OR
  • Nonmusculoskeletal or nonneuromusculoskeletal conditions; OR
  • Treatments for sports related rehabilitation* or other similar avocational activities such as, but may not be limited to:
    • Baseball pitching/throwing
    • Cheerleading
    • Golfing
    • Martial arts of all types
    • Organized football, baseball, basketball, soccer, lacrosse, swimming, track and field, etc.
  • at a college, high school, other school or community setting
  • Personal return to running rehabilitation
  • Professional and amateur tennis
  • Professional and amateur/hobby/academic dance
  • Weightlifting and similar activities

*Refers to continued treatment for sports related injuries in an effort to improve above and beyond normal ability to perform ADLs; it is not intended to return the individual to their previous (or improved) level of sports competition or capability.

Chiropractic Care Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0384-020
Page: 7 of 14

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

These are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for chiropractic care for temporomandibular joint disorders as this is generally excluded by certificate, please refer to the member's individual certificate. In the absence of a certificate exclusion, this is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for chiropractic care utilizing any of the following diagnostic or treatment techniques including, but may not be limited to:

  • Chiropractic Biophysics (CBP); OR
  • Computerized inclinometer ROM device (eg, Dual Inclinometer Range of Motion device); OR
  • Computerized muscle testing; OR
  • Digital postural analysis; OR
  • Digitalizing of X-rays (also known as a roentgenometric procedure including, but not limited to, the Spinalyzer); OR
  • Dry hydrotherapy, also known as hydromassage, aqua massage or water massage (eg, Aqua Massage, Aqua MED, H2O Massage System and Hydrotherapy Tables); OR
  • Matrix therapies (also known as Matrix Regeneration Therapy); OR
  • Microcurrent (also known as Acuscope or Electro-acuscope); OR
  • National Upper Cervical Chiropractic Association (NUCCA) technique; OR
Chiropractic Care Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0384-020
Page: 8 of 14

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Thermography (also known as a paraspinal thermal scan); OR

therapy, intervertebral differential dynamics therapy, intervertebral disc decompression (IDD) or powered traction device (eg, Accu-Spina System, Decompression Reduction Stabilization [DRS] System, DRX 9000, DX2 Decompression System, Integrity Spinal Care System, Intervertebral Differential Dynamics Therapy [IDD Therapy], Lordex Lumbar Spine System, MTD 4000 Mettler Traction Decompression System, SpineRx-LDM and VAX-D Spinal Decompression System)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-review medical literature published in the English language.

Additional information about musculoskeletal conditions and chiropractic care may be found from the following websites:

Background

  • American Academy of Orthopaedic Surgeons
  • American Chiropractic Association
  • American College of Rheumatology
  • National Institute of Arthritis and Musculoskeletal and Skin Diseases
  • National Institute of Neurological Disorders and Stroke
  • National Library of Medicine

Medical Alternatives

Alternatives to chiropractic care include, but may not be limited to, the following:

  • Occupational or physical therapy (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)
  • Pain management

Physician consultation is advised to make an informed decision based on an individual's health needs.

Chiropractic Care Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0384-020
Page: 9 of 14

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Provider Claims Codes

cPT® Code(s): 29200, 29240, 29260, 29280, 29520, 29530, 29540, 29550

Description: Strapping; thorax, shoulder (eg, Velpeau), elbow or wrist, hand or finger, hip, knee, ankle and/or foot

Comments: Not Covered if used to report Kinesio taping

Strapping; toes Not Covered if used to report Kinesio taping

29799 Unlisted procedure, casting or strapping Not Covered if used to report Kinesio taping

97012 Application of a modality to 1 or more areas; traction, mechanical

Chiropractic Care Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0384-020
Page: 10 of 14

this is the current version before utilizing.

97039 Unlisted modality (specify type and time if constant attendance) Not Covered if used to report chiropractic care outlined in Coverage Limitations

97139 Unlisted therapeutic procedure (specify) Not Covered if used to report chiropractic care outlined in Coverage Limitations

97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes Not Covered if used to report any treatment outlined in Coverage Limitations section augmented soft tissue mobilization or Graston® Technique

97545 Work hardening/conditioning; initial 2 hours Not Covered

97546 Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure) Not Covered

97799 Unlisted physical medicine/rehabilitation service or procedure

98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions

98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions

98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions

98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions

Provider Claims Codes

CPT® Category III Code(s):

  • 0347T Placement of interstitial device(s) in bone for radiostereometric analysis (RSA) Not Covered
  • 0348T Radiologic examination, radiostereometric analysis (RSA); spine, (includes cervical, thoracic and lumbosacral, when performed) Not Covered
  • 0349T Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow, and wrist, when performed) Not Covered
Chiropractic Care Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0384-020
Page: 11 of 14

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

References

  • Agency for Healthcare Research and Quality (AHRQ). Evidence Report/Technology Assessment (ARCHIVED). Complementary and alternative therapies for back pain II. https://www.ahrq.gov. Published October 2010. Accessed June 14, 2023.
  • Agency for Healthcare Research and Quality (AHRQ). Noninvasive nonpharmacological treatment for chronic pain: a systemic review update. https://www.ahrq.gov. Published June 11, 2018. Updated April 2020.

0350T Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee, and ankle, when performed) Not Covered

HCPCS Code(s):

  • 58990 Physical or manipulative therapy performed for maintenance rather than restoration Not Covered
  • S9090 Vertebral axial decompression, per session Not Covered
  • S9117 Back school, per visit Not Covered
  • American College of Physicians (ACP). Noninvasive treatments for acute, subacute and chronic low back pain: a clinical practice guideline from the American College of Physicians. https://www.acponline.org. Published April 4, 2017. Accessed June 16, 2023.
  • Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual (240). Covered medical and other health services. Published October 1, 2003. https://www.cms.gov. Accessed June 16, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Fluidized therapy dry heat for certain musculoskeletal disorders (150.8). https://www.cms.gov. Accessed June 16, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Manipulation (150.1). https://www.cms.gov. Accessed June 16, 2023.
Chiropractic Care Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0384-020
Page: 12 of 14

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Vertebral axial decompression (VAX-D) (160.16). https://www.cms.gov. Published April 15, 1997. Accessed June 16, 2023.
  • Council on Chiropractic Practice. Clinical practice guideline: subluxation chiropractic practice. https://www.ccp-guidelines.org. Published 1998. Updated 2013. Accessed June 16, 2023.
  • ECRI Institute. Hotline Response (ARCHIVED). Decompression therapy for lumbosacral pain. https://www.ecri.org. Published July 20, 2015. Accessed June 12, 2023.
  1. Hayes, Inc. Evidence Analysis Research Brief. Kinesio taping for management of chronic low back pain. https://evidence.hayesinc.com. Published May 26, 2022. Accessed June 13, 2023.
  2. Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Spinal manipulation for treatment of chronic low back pain. https://evidence.hayesinc.com. Published March 4, 2020. Accessed June 6, 2022.
  3. Hayes, Inc. Health Technology Brief (ARCHIVED). Kinesio taping method (Kinesio Holding Corp.) for injury and rehabilitation. https://evidence.hayesinc.com. Published April 25, 2011. Updated May 1, 2013. Accessed June 13, 2023.
  4. Hayes, Inc. Medical Technology Directory (ARCHIVED). Chiropractic treatment for low back pain. https://evidence.hayesinc.com. Published November 3, 2005. Updated December 14, 2009. Accessed June 13, 2023.
  5. Hayes, Inc. Medical Technology Directory (ARCHIVED). Mechanized spinal distraction therapy for low back pain. https://evidence.hayesinc.com. Published January 13, 2003. Updated January 3, 2008. Accessed June 13, 2023.
  6. Hayes, Inc. Search & Summary (ARCHIVED). Chiropractic Biophysics (CBP) for segmented somatic dysfunction of spinal regions. https://evidence.hayesinc.com. Published February 26, 2019. Accessed June 8, 2021.
Chiropractic Care Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0384-020
Page: 13 of 14

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • International Chiropractors Association. Best practices & practice guidelines. Frequency & duration recommendations. https://www.chiropractic.org. Published April 2008. Updated November 22, 2013. Accessed June 16, 2023.
  • MCG Health.
    1. MCG Health. Spinal manipulation therapy (SMT), chiropractic and other. 27th edition. https://www.mcg.com. Accessed June 21, 2023.
    2. MCG Health. Traction, spine. 27th edition. https://www.mcg.com. Accessed June 21, 2023.
    3. North American Spine Society (NASS). Evidence-based clinical guidelines for multidisciplinary spine care. Diagnosis and treatment of cervical radiculopathy from degenerative disorders. https://www.spine.org. Published 2010. Accessed June 16, 2023.
    4. North American Spine Society (NASS). Evidence-based clinical guidelines for multidisciplinary spine care. Diagnosis and treatment of degenerative lumbar spinal stenosis. https://www.spine.org. Published 2011. Accessed June 16, 2023.
    5. North American Spine Society (NASS). Evidence-based clinical guidelines for multidisciplinary spine care. Diagnosis and treatment of low back pain. https://www.spine.org. Published 2020. Accessed June 16, 2023.
    6. North American Spine Society (NASS). Evidence-based clinical guidelines for multidisciplinary spine care. Diagnosis and treatment of lumbar disc herniation with radiculopathy. https://www.spine.org. Published 2012. Accessed June 16, 2023.
    7. UpToDate, Inc. Complementary, alternative, and integrative therapies for asthma. https://www.uptodate.com. Updated May 2023. Accessed June 14, 2023.
    8. UpToDate, Inc. Complementary and integrative health in pediatrics. https://www.uptodate.com. Updated May 2023. Accessed June 14, 2023.
    9. UpToDate, Inc. Infantile colic: management and outcome. https://www.uptodate.com. Updated May 2023. Accessed June 14, 2023.
    10. UpToDate, Inc. Management of non-radicular neck pain in adults. https://www.uptodate.com. Updated June 12, 2023. Accessed June 14, 2023.
    11. UpToDate, Inc. Spinal manipulation in the treatment of musculoskeletal pain. https://www.uptodate.com. Updated June 2, 2023. Accessed June 14, 2023.
    12. UpToDate, Inc. Subacute and chronic low back pain: nonpharmacologic and pharmacologic treatment. https://www.uptodate.com. Updated May 2023. Accessed June 14, 2023.
    13. UpToDate, Inc. Treatment of acute low back pain. https://www.uptodate.com. Updated May 2023. Accessed June 14, 2023.
    Chiropractic Care Effective Date: 07/27/2023
    Revision Date: 07/27/2023
    Review Date: 07/27/2023
    Policy Number: HUM-0384-020
    Page: 14 of 14

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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