DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

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

Definitions

Highmark Health Options (HHO)- Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services WV Mountain Health Trust (MHT) and West Virginia Health Bridge (WVHB) including an expansion plan (WVHB ABP Alternative Benefit Plan) and WVCHIP members.

Chiropractic Manipulation- Application of a controlled force to restore normal articular function.

Manual Manipulation- Use of the hands directed to the spine to correct subluxation. This refers to chiropractic services only.

Subluxation- A lack of motion, fixation, or abnormal motion of an articular joint, causing physiological changes within the joint that may result in joint inflammation, pain, nerve irritation, muscle spasm, swelling, joint cartilage damage, and loss of normal range of motion.

Prior Authorization

All requests for covered services requiring prior authorization must be submitted to the appropriate utilization management contractor (UMC) for medical necessity determination. Nationally accredited, evidence-based, medically appropriate criteria, such as InterQual, or other medical appropriateness criteria approved by the Bureau for Medical Services (BMS), is utilized for reviewing medical necessity of services requested.

An x-ray report must be submitted with the prior authorization request for spinal manipulations beyond the initial 20 treatments. The x-ray must be taken no more than three months prior to the date the additional spinal manipulations would be rendered in order to substantiate the necessity for continuing chiropractic care. The x-ray requirement is waived for pregnant women.

Retrospective authorization is available by the UMC in the following circumstances:

• A procedure/service denied by the member’s primary payer, providing all requirements for the primary payer have been followed, including appeal processes; or

• Retroactive West Virginia Medicaid eligibility.

Procedures

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

Services are limited to a combined total of 20 visits per year of physical therapy, occupational therapy, and chiropractic treatment. All services beyond the initial 20 treatments require prior authorization.

Chiropractors may submit claims using the appropriate basic and mid-level new patient evaluation and management (E&M) procedure codes.

West Virginia Medicaid reimburses chiropractors for the professional and technical components of specific covered diagnostic radiology services if the chiropractor performs both parts of the procedure. Medicaid will provide reimbursement for only one interpretation of an x-ray and will not pay for a second confirmatory x-ray.

The manual manipulation must be directed to the spine to correct the subluxation. The precise level of the subluxation must be specified in the medical record and the symptoms pertinent to the treatment must be described. The patient’s symptoms must be related to the documented level of subluxation. For example, if pain is the symptom, the pain’s location must be stated and an indication given as to whether the listed vertebrae can cause the pain in the identified area.

For acute subluxation, the member is being treated for a new injury and the expected result of treatment is improvement in the member’s condition. Chronic subluxation is not expected to completely resolve and the result of treatment is to be some functional improvement. Once the member’s functional status has remained stable for the condition being treated, further manipulative treatment is considered “maintenance therapy” and is not covered.

NONCOVERED SERVICES

Chiropractic manipulation is not covered when:

• An absolute contraindication exists, such as:

o Acute/healed fractures and dislocations, with signs of instability;

o Malignancies that involve the vertebral column;

o Infection of bones or joints of the vertebral column; or

o Signs and symptoms of myelopathy or cauda equine syndrome.

• Mechanical or electrical equipment is used.

• The x-ray does not support one of the primary covered diagnoses.

When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, then the treatment is considered maintenance therapy. Maintenance therapy is not covered by West Virginia Medicaid.

Adjunctive therapies that are not covered include, but are not limited to:

• Laboratory tests;

• Mobile radiology services;

• X-rays for soft tissue diagnosis;

• Maintenance therapy; and

• Hot and cold packs therapy.

Non-Covered services are not eligible for West Virginia Department of Health and Human Resources (DHHR) Fair Hearings or Desk/Document Reviews.

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. 

Evaluation and Management Services