Appeal type: unknown
Decision: unknown

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 Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3. 
 
The rules say that Chiropractic Services Active Treatment: 
 
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. (CMS Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3) 
 
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. (CMS Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 240.1.3) 
 
An acute exacerbation is a temporary but marked deterioration of the patient's condition that is causing 
significant interference with activities of daily living 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 seek 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 the chiropractic treatment 
becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. 
(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A) 
 
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. (CMS Publication 100-02, Medicare Benefit Policy Manual, 
Chapter 15, Section 240.1.3B) 
The following are relative contraindications to Dynamic thrust: 
 
        Articular hyper mobility and circumstances where the stability of the joint is uncertain;  
        Severe demineralization of bone;  
        Benign bone tumors (spine);  
        Bleeding disorders and anticoagulant therapy; and  
        Radiculopathy with progressive neurological signs. 
 
(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section240.1.3B) Dynamic thrust is 
absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the 
following: 
 
        Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation 
or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;  
        Acute fractures and dislocations or healed fractures and dislocations with signs of instability;  
        An unstable os odontoideum;  
        Malignancies that involve the vertebral column;  
        Infection of bones or joints of the vertebral column;  
        Signs and symptoms of myelopathy or cauda equina syndrome;  
        For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and  
        A significant major artery aneurysm near the proposed manipulation. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): CHIROPRACTIC Services 
(L37254). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.