Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic services (code 98940) or pay 
for codes 97124 and 95851 provided on March 30, 2021 to December 5, 2021. 
 
You asked the Plan to waive the copayment for chiropractic services (code 98940) and pay for codes 97124 
and 95851. You say that you disagree with the amount the Plan paid for code 98940, and that codes 97124 and 
95851 should be covered by the Plan as well. The Plan denied your request. The Plan says covered services for 
chiropractic care include only manual manipulation of the spine to correct subluxation (code 98940), and the 
copayment amount charged is correct. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each Medicare-covered visit.  
 
Date(s) of Service 
Service 
Provided 
Code 
Fee 
Charged 
Allowed 
Amount 
Cost-Share 
Per Contract 
Your Cost-Share 
Responsibility 
March 30, 2021 
Spinal 
Manipulation 
98940 $26 $26 
$20 
copayment 
$20 
March 30, 2021 
Massage 
therapy 
97124 $25 0 Not covered $25 
March 30, 2021 Muscle test 95831 $25 0 Not covered $25 
May 05, 2021 
Spinal 
Manipulation 
98940 $26 $26 
$20 
copayment 
$20 
May 05, 2021 
Massage 
therapy 
97124 $25 0 Not covered $25 
May 05, 2021 Muscle test 95831 $25 0 Not covered $25 
June, 01, 2021 
Spinal 
Manipulation 
98940 $26 $26 
$20 
copayment 
$20 
June, 01, 2021 
Massage 
therapy 
97124 $25 0 Not covered $25 
June, 01, 2021 Muscle test 95831 $25 0 Not covered $25 
June 14, 2021 
Spinal 
Manipulation 
98940 $26 $26 
$20 
copayment 
$20 
June 14, 2021 
Massage 
therapy 
97124 $25 0 Not covered $25 
June 14, 2021 Muscle test 95831 $25 0 Not covered $25 
July 28, 2021 
Spinal 
Manipulation 
98940 $26 $26 
$20 
copayment 
$20 
July 28, 2021 
Massage 
therapy 
97124 $25 0 Not covered $25 
July 28, 2021 Muscle test 95831 $25 0 Not covered $25 September 15, 2021 
Spinal 
Manipulation 
98940 $26 $26 
$20 
copayment 
$20 
September 15, 2021 
Massage 
therapy 
97124 $25 0 Not covered $25 
September 15, 2021 Muscle test 95831 $25 0 Not covered $25 
November 22, 2021 
Spinal 
Manipulation 
98940 $26 $29 
$20 
copayment 
$20 
November 22, 2021 
Massage 
therapy 
97124 $29 0 Not covered $29 
November 22, 2021 Muscle test 95831 $29 0 Not covered $29 
December 20, 2021 
Spinal 
Manipulation 
98940 $26 $26 
$20 
copayment 
$20 
December 20, 2021 
Massage 
therapy 
97124 $29 0 Not covered $29 
December 20, 2021 Muscle test 95831 $29 0 Not covered $29 
December 20, 2021 
Outpatient 
MED supply 
A9270 $77.50 0 Not covered $77.50 
Total      $653.50 
 
 
  You have been asked to pay a total of $653.50 for 8 visits of chiropractic services.  
 
Chiropractic services falls within the Chiropractic Services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for chiropractic services (code 98940) or pay for codes 97124 and 95851 provided on 
March 30, 2021 to December 5, 2021.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that codes 97124 and 95851 at issue is not manual manipulation of the spine. Therefore, we 
decided that the Plan does not have to pay for chiropractic services (codes 97124 and 95851) provided on 
March 30, 2021 to December 5, 2021.