Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.8 - Chiropractors

Current through Register Vol. 47, No. 3, July 24, 2024
Payment will be made for the same chiropractic procedures
				  payable under Title XVIII of the Social Security Act (Medicare).
(1)
Covered services.
Chiropractic manipulative therapy (CMT) eligible for reimbursement is
				specifically limited by Medicaid to the manual manipulation (i.e., by use of
				the hands) of the spine for the purpose of correcting a subluxation
				demonstrated by X-ray. Subluxation means an incomplete dislocation,
				off-centering, misalignment, fixation, or abnormal spacing of the
				vertebrae.
(2)
Indications
				and limitations of coverage.
a. The
				subluxation must have resulted in a neuromusculoskeletal condition set forth in
				the table below for which CMT is appropriate treatment. The symptoms must be
				directly related to the subluxation that has been diagnosed. The mere statement
				or diagnosis of "pain" is not sufficient to support the medical necessity of
				CMT. CMT must have a direct therapeutic relationship to the patient's
				condition. No other diagnostic or therapeutic service furnished by a
				chiropractor is covered under the Medicaid program.
ICD
CATEGORY I
ICD
CATEGORY II
ICD
CATEGORY III
G44.1
Vascular headache NEC*
G54.0-
G54.4
Nerve root and plexus
disorders, brachial plexus disorders, lumbosacral
							 plexus disorders, cervical root disorders NEC, thoracic root disorders NEC,
							 lumbosacral root disorders NEC
M48.30-
M48.33
Traumatic spondylopathy,
site unspecified, occipito-atlanto-axial region,
							 cervical region, cervicothoracic region
G44.209
Tension headache,
G54.8
Other nerve root and
M48.35-
Traumatic spondylopathy,
unspecified, not intractable
plexus disorders
M48.38
thoracolumbar region, lumbar region, lumbosacral
							 region, sacral and sacrococcygeal region
M47.21-
M47.28
Other spondylosis
with radiculopathy, occipito-atlanto-axial region,
							 cervical region, cervicothoracic region, thoracic region, thoracolumbar region,
							 lumbar region, lumbosacral region, sacral and sacrococcygeal region
G54.9
Nerve root and plexus
disorder, unspecified
M50.20-
M50.23
Other cervical disc
displacement
M47.811-
M47.818
Spondylosis without
myelopathy or radiculopathy, occipito-atlanto-axial
							 region, cervical region, cervicothoracic region, thoracic region, thoracolumbar
							 region, lumbar region, lumbosacral region, sacral and sacrococcygeal
							 region
G55
Nerve root and plexus
compressions in diseases classified elsewhere
M50.30-
M50.33
Other cervical disc
degeneration
M47.891-M47.898
Other spondylosis, occipito-atlanto-axial region,
							 cervical region, cervicothoracic region, thoracic region, thoracolumbar region,
							 lumbar region, lumbosacral region, sacral and sacrococcygeal region
M43.00-M43.28
Spondylolysis; spondylolisthesis; fusion of
							 spine
M51.24-M51.27
Other thoracic, thoracolumbar and lumbosacral
							 intervertebral disc displacement
M54.2
Cervicalgia
M43.6
Torticollis
M51.34-M51.37
Other thoracic, thoracolumbar and lumbosacral
							 intervertebral disc degeneration
M54.5
Low back pain
M46.00-M46.09
Spinal enthesopathy
M54.30-M54.32
Sciatica
M54.6
Pain in the thoracic spine
M46.41-M46.47
Discitis, unspecified, occipito-atlanto-axial
							 region, cervical region, cervicothoracic region, thoracic region, thoracolumbar
							 region, lumbar region, lumbosacral region
M54.40-M54.42
Lumbago with sciatica
M54.81
Occipital neuralgia
M48.00-M48.08
Spinal stenosis
M96.1
Postlaminectomy syndrome, NEC
M54.89
Other dorsalgia
M48.34
Traumatic spondylopathy, thoracic region
M54.9
Dorsalgia, unspecified
M50.10-M50.13
Cervical disc disorder with radiculopathy
R51
Headache
M50.80-M50.83
Other cervical disc disorders
M50.90-M50.93
Cervical disc disorder, unspecified
M51.14-M51.17
Intervertebral disc disorders with radiculopathy,
							 thoracic region, thoracolumbar region, lumbar region, lumbosacral region
M51.84-M51.87
Other thoracic, thoracolumbar and lumbosacral
							 intervertebral disc disorders
M53.0
Cervicocranial syndrome
M53.1
Cervicobrachial syndrome
M53.2X1-M53.2X9
Spinal instabilities
M53.3
Sacrococcygeal disorders NEC
M53.80
Other specified dorsopathies, site
							 unspecified
M53.84-M53.88
Other specified dorsopathies, thoracic region,
							 thoracolumbar region, lumbar region, lumbosacral region, sacral and
							 sacrococcygeal region
M53.9
Dorsopathy, unspecified
M54.10-M54.18
Radiculopathy
M60.80
Other myositis, unspecified site
M60.811, M60.812
Other myositis, shoulder, right, left
M60.819
Other myositis, unspecified shoulder
M60.821, M60.822
Other myositis, upper arm, right, left
M60.829
Other myositis, unspecified upper arm
M60.831, M60.832
Other myositis, forearm, right, left
M60.839
Other myositis, unspecified forearm
M60.841, M60.842
Other myositis, hand, right, left
M60.849
Other myositis, unspecified hand
M60.851, M60.852
Other myositis, thigh, right, left
M60.859
Other myositis, unspecified thigh
M60.861, M60.862
Other myositis, lower leg, right, left
M60.869
Other myositis, unspecified lower leg
M60.871, M60.872
Other myositis, ankle and foot, right, left
M60.879
Other myositis, unspecified ankle and foot
M60.88, M60.89
Other myositis, other site, multiple sites
M60.9
Myositis, unspecified
M62.830
Muscle spasm of back
M72.9
Fibroblastic disorder, unspecified
M79.1
Myalgia
M79.2
Neuralgia and neuritis, unspecified
M79.7
Fibromyalgia
M99.20-M99.23
Subluxation stenosis of neural canal, head region,
							 cervical region, thoracic region, lumbar region
M99.30-M99.33
Osseous stenosis of neural canal, head region,
							 cervical region, thoracic region, lumbar region
M99.40-M99.43
Connective tissue stenosis of neural canal, head
							 region, cervical region, thoracic region, lumbar region
M99.50-M99.53
Intervertebral disc stenosis of neural canal, head
							 region, cervical region, thoracic region, lumbar region
M99.60-M99.63
Osseous and subluxation stenosis of intervertebral
							 foramina, head region, cervical region, thoracic region, lumbar region
M99.70-M99.73
Connective tissue and disc stenosis of
							 intervertebral foramina, head region, cervical region, thoracic region, lumbar
							 region
Q76.2
Congenital spondylolisthesis
S13.4XXA,
S13.4XXD
Sprain of ligaments of cervical spine, initial
							 encounter, subsequent encounter
S13.8XXA,
S13.8XXD
Sprain of joints and ligaments of other parts of
							 neck, initial encounter, subsequent encounter
S16.1XXA, S16.1XXD
Strain of muscle, fascia and tendon at neck level,
							 initial encounter, subsequent encounter
S23.3XXA,
S23.3XXD
Sprain of ligaments of thoracic spine, initial
							 encounter, subsequent encounter
S23.8XXA,
S23.8XXD
Sprain of other specified parts of thorax, initial
							 encounter, subsequent encounter
S33.5XXA,
S33.5XXD
Sprain of ligaments of lumbar spine, initial
							 encounter, subsequent encounter
S33.6XXA,
S33.6XXD
Sprain of sacroiliac joint, initial encounter,
							 subsequent encounter
* NEC means not elsewhere classified.
b. The neuromusculoskeletal conditions listed
				in the table in paragraph
"a"
generally require short-,
				moderate-, or long-term CMT. A diagnosis or combination of diagnoses within
				Category I generally requires short-term CMT of 12 per 12-month period. A
				diagnosis or combination of diagnoses within Category II generally requires
				moderate-term CMT of 18 per 12-month period. A diagnosis or combination of
				diagnoses within Category III generally requires long-term CMT of 24 per
				12-month period. For diagnostic combinations between categories, 28 CMTs are
				generally required per 12-month period. If the CMT utilization guidelines are
				exceeded, documentation supporting the medical necessity of additional CMT must
				be submitted with the Medicaid claim form or the claim will be denied for
				failure to provide information.
c.
				CMT is not a covered benefit when:
(1) The
				maximum therapeutic benefit has been achieved for a given condition.
(2) There is not a reasonable expectation
				that the continuation of CMT would result in improvement of the patient's
				condition.
(3) The CMT seeks to
				prevent disease, promote health and prolong and enhance the quality of
				life.