Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the chiropractic manipulative treatments 
(98941 x 4), office visits (99212 x 2), and the x-ray exam of the lumbar spine (72100) provided from April 5, 
2023, through June 1, 2023. Additionally, the Plan does not have to pay for the unlisted modality (97039), 
vertebral axial decompression, per session (S9090), and the non-covered item or service (A9270) provided 
from April 5, 2023, through June 1, 2023. 
 
You asked the Plan to waive the cost share for these services. You also asked the Plan to pay for the non-
covered services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. The Plan says the non-covered 
services were denied appropriately. 
 
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 $10 
copayment for each Medicare-covered chiropractic service. You must also pay a $10 copayment for each non-
Medicare covered routine chiropractic visit. Additionally, the deductible applies to non-Medicare covered x-ray 
services performed by an out-of-network chiropractor.   
 
The Plan must follow Medicare rules. Medicare rules say that the only covered service is manual manipulation 
of the spine to correct a subluxation. Additionally, the Plan provides supplemental coverage for non-Medicare 
covered routine visits for conditions including, but not limited to, back pain, neck pain, and headaches.  
 
You have been asked to pay $100. This amount includes a $10 copayment x 4= $40 for the Medicare-covered 
chiropractic services provided. This amount also includes a $10 copayment x 2= $20 for the non-Medicare 
covered routine chiropractic visits provided. Additionally, this includes the Plans allowed amount of $40 for 
the non-Medicare covered x-ray service performed by an out-of-network chiropractor. This service is subject to 
the deductible. 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. 
Additionally, the only Medicare-covered covered chiropractic service is manual manipulation of the spine to 
correct a subluxation. The Plan provides supplemental coverage for non-Medicare covered routine visits to be 
used for conditions including, but not limited to, back pain, neck pain, and headaches. Therefore, we decided 
that the Plan does not have to waive the cost share for the chiropractic manipulative treatments (98941 x 4), 
office visits (99212 x 2), and the x-ray exam of the lumbar spine (72100) provided from April 5, 2023, through 
June 1, 2023. Additionally, the Plan does not have to pay for the unlisted modality (97039), vertebral axial 
decompression, per session (S9090), and the non-covered item or service (A9270) provided from April 5, 2023, 
through June 1, 2023.