Purpose 

This medical policy outlines Highmark Health Options services for chiropractic benefits and services.

Definitions

Highmark Health Options Duals (HHO Duals) – Highmark Health Options Duals is designed for people with both Medicare and Medicaid. Our D-SNP Medicare Advantage HMO coverage offers the same benefits as Original Medicare, plus extra benefits, like prescription drug coverage and vision and dental care.

Adjunctive Procedures – Any therapeutic maneuver ancillary to the care needed short term to stabilize a patient, by which reduces the morbidity and mortality long term.

Chiropractic manipulative treatment (CMT) – A form of manual treatment to influence joint and neurophysiological function. This treatment may be accomplished using a variety of techniques.

Medical Necessity – Providing health care services or products that a prudent physician would provide to a patient for the purpose of diagnosing or treating illness, injury, disease, or its symptoms in a manner that is all of the following: in accordance with generally accepted standards of chiropractic practice, consistent with the symptoms or treatment of the condition, and not solely for anyone’s convenience.

Active Treatment-Active treatment is when a patient is being treated for a new injury, identified by x-ray or physical exam. Result of chiropractic manipulation is expected to be improvement in, or arret of progression, of patient’s condition.

Maintenance Treatment-includes “services that seeks to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and chiropractic treatment becomes supportive rather than corrective in nature, treatment is then considered maintenance therapy.” 

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Prior authorization is required for all chiropractic services as follows:

For active chiropractic care (standard benefit):

No prior authorization is required for initial visit but is required after 30 visits.

For routine/maintenance chiropractic care (supplemental benefit):

No prior authorization required; however, there is a 20-visit limit, annually.

Procedures

PROVIDER REQUIREMENTS/QUALIFICATIONS

Qualified chiropractors must be licensed per Medicare licensure requirements.

EVALUATION AND MANAGEMENT SERVICES

Manipulation includes a pre-manipulation assessment. Time-based physical medicine services also include the time required to perform all aspects of the service, including pre-, intra-, and post-service work.

A 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.

COVERED SERVICES

The practice of chiropractic includes, but is not limited to, the diagnosing and locating of misaligned or displaced vertebrae (subluxation complex), using x-rays and other diagnostic test procedures. Practice of chiropractic includes the treatment through manipulation/adjustment of the spine and other skeletal structures and the use of adjunctive procedures not otherwise prohibited by the applicable state license limitations.

Chiropractic services involve manipulation associated with the treatment of neck, back, and pelvic/sacral. Allowable adjunctive therapy associated with the treatment of neck, back, pelvic/sacral, and extraspinal pain and/or dysfunction, that the chiropractor is legally authorized by the State to perform per state code. Chiropractic services are subject to prior authorization and/or medical review.

Manipulations should be provided in accordance with an ongoing, written treatment plan and must be appropriate for the diagnosis reported. The treatment plan should be updated as the patient's condition changes and maintained in the medical records. Manipulations can be provided manually or with the assistance of various mechanical or computer operated devices. No additional payment is available for use of the device or for the device itself.

NONCOVERED SERVICES

The following are items or services that are non-covered chiropractic services:

·       Vitamins

·       Minerals.

·       Supplements.

·       Any other chiropractic service not defined in this benefit.

·       Chiropractic maintenance therapy is not considered to be medically necessary and is not covered when provided to Medicare recipients who         do not suffer from chronic pain and/or dysfunction and continued therapy can be expected to result in some functional improvement or         prevent deterioration of a chronic condition.

·       Orthopedic devices prescribed by chiropractor.

·       Treatment for any condition not related to a diagnosis of subluxation or neck, back, pelvic/sacral, and extraspinal pain and/or dysfunction.

·       Any services outside of scope of state licensure.

·       Room and Board fees are not covered.

·       Hand-held and other devices may be used in treatment but are not eligible to be reimbursed.

·       Experimental/Investigational (E/I) services are not covered regardless of place of service.

·       Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as noncovered.

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

Chiropractic claims must be billed on a CMS-1500 claim, or if billing electronically, the 837 professional claim using appropriate chiropractic CPT codes.

Active Chiropractic Care

Note: All active chiropractic services must be billed with the AT modifier.

Routine/Maintenance Chiropractic Care