Chiropractic manipulative treatment (CMT) is a form of manual treatment to
influence joint and neurophysiological function. This treatment may be
accomplished using a variety of techniques. Medicare covers limited
chiropractic services when carried out by a chiropractor who is legally
authorized or licensed to provide chiropractic services by the State or
jurisdiction in which the services are provided. A chiropractor must also meet
uniform minimum standards as set forth in the Centers for Medicare and
Medicaid Services (CMS) Internet-Only Manual (IOM). This policy restates
language directly from the CMS IOMs and if necessary provides clarification to
educate providers on specified Medicare requirements for the diagnosis,
treatment, documentation and billing of chiropractic services.  
  
**Indications  
  
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.  
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.  
  
The following are relative contraindications to dynamic thrust:

    * Articular hypermobility 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.

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.

**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,
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.