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Medical Necessity Defined by carriers:

Medicare defines medical necessity for CMT: “The patient must have a significant health problem in the form of a MUSCULOSKELETAL or a NEUROMUSCULOSKELETAL CONDITION necessitating treatment, and the manipulative services rendered must have a DIRECT THERAPEUTIC RELATIONSHIP to the patient’s condition and provide reasonable expectations of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by X-ray or physical exam.”

Aetna: “Aetna considers chiropractic services medically necessary when all of the following criteria are met: A) The member has a NEUROMUSCULOSKELETAL disorder; and B) The medical necessity for treatment is clearly documented; and C) Improvement is documented within the initial 2 weeks of chiropractic care…. MANIPULATION IS CONSIDERED EXPERIMENTAL AND INVESTIGATIONAL WHEN IT IS RENDERED FOR NON-NEUROMUSCULOSKELETAL CONDITIONS (e.g., attention-deficit hyperactivity disorder, dysmenorrhea, epilepsy; and gastro-intestinal disorders, not an all inclusive list) because its effectiveness for these indications is unproven.”

Optum / United Healthcare: “… spinal or extraspinal manipulative/mobilization therapy FOR THE TREATMENT OF NONMUSCULOSKELETAL DISORDERS TO BE UNPROVEN, AND INVESTIGATIONAL OR EXPERIMENTAL due to insufficient research evidence of safety and or efficacy in the clinical setting.”

Highmark BCBShttps://www.highmarkblueshield.com/pdf_file/HighmarkBlueShield-Section15.pdf  Spinal Manipulation therapy is a covered service when performed with the expectation of restoring the patient’s level of function that has been lost or reduced by injury or illness. However, manipulation therapy is not eligible when performed repetitively to maintain a level of function.