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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare does not cover chiropractic maintenance care. When further clinical improvement cannot be reasonably expected from ongoing care, the care is considered maintenance. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3.

The rules say that the 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. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam. Most spinal joint problems fall into the following categories: Acute subluxation - A patient's condition is considered acute when the patient is being treated for a new injury identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in or arrest of progression of the patient's condition. Chronic subluxation - A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition) but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered. An acute exacerbation is a temporary but marked deterioration of the patient's condition that is causing significant interference with activities of daily living (ADLs) due to an acute flare-up of the previously treated condition. The patient's clinical record must specify the date of occurrence, nature of the onset or other pertinent factors that would support the medical necessity of treatment. As with an acute injury, treatment should result in improvement or arrest of the deterioration within a reasonable period of time. A. Maintenance Therapy: Maintenance therapy includes services that attempt to avert disease, facilitate health and extend and improve the quality of life; or therapy that is implemented to preserve or avoid deterioration of a chronic condition. The treatment is considered maintenance therapy when additional clinical advancement cannot logically be expected from constant ongoing care and the chiropractic treatment becomes auxiliary rather than curative in nature. B. Contraindications: Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. Limitations: The specified qualifying requirements for the term "physician", which includes a chiropractor, and the coverage extensions to treat by means of manual manipulation of the spine to correct a subluxation are set forth in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30.5 Physician Services-Chiropractor's Services. The mere statement or diagnosis of "pain" is not sufficient to support medical necessity for the treatments. The precise level(s) of the subluxation(s) must be specified by the chiropractor to substantiate a claim for manipulation of each spinal region(s). There are 5 spinal regions addressed by this local coverage determination (LCD): cervical region (atlanto-occipital joint), thoracic region (costovertebral/costotransverse joints), lumbar region, pelvic region (sacro-iliac joint) and sacral region. Medicare does not cover chiropractic treatments to extraspinal regions. The 5 extraspinal regions are: head (including temporomandibular joint, excluding atlanto-occipital) region, lower extremities, upper extremities, rib cage (excluding costotransverse and costovertebral joints) and abdomen. The need for a prolonged course of treatment should be appropriate to medical necessity and must be documented clearly in the medical record. You can find this information in Medicare's Local Coverage Determination (LCD): Chiropractic Services (L37387).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.