This policy version was replaced October 31, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Minnesota statute 148.01, which defines chiropractic services, includes the evaluation and treatment of structural, biomechanical and neurological function and integrity through the use of adjustment, manipulation, mobilization or other procedures accomplished by manual or mechanical forces applied to bones or joints and their related soft tissues. The goal of chiropractic services is to correct vertebral subluxation or other abnormal articulations, neurological disturbances, structural alterations or biomechanical alterations.
Minnesota Rule 2500.0100 Subpart 11 defines rehabilitative therapy performed by a chiropractor as “Therapy that restores an ill or injured patient to the maximum functional improvement by employing within the practice of chiropractic those methods, procedures, modalities, devices, and measures which include mobilization; thermotherapy; cryotherapy; hydrotherapy; exercise therapies; nutritional therapy; meridian therapy; vibratory therapy; traction; stretching; bracing and supports; trigger point therapy; massage and the use of forces associated with low voltage myostimulation, high voltage myostimulation, ultraviolet light, diathermy, and ultrasound; and counseling on dietary regimen, sanitary measures, occupational health, lifestyle factors, posture, rest, work, and recreational activities that may enhance or complement the chiropractic adjustment.”
Maintenance therapy is defined by the Centers of Medicare and Medicaid Services (CMS) as a “Treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to 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.”
Blue Cross Blue Shield of Minnesota has additional policies on specific tests and treatments related to chiropractic services. These include but are not limited to the following (policy numbers in parentheses):
I. Initial Evaluation and Treatment
Chiropractic services may be considered MEDICALLY NECESSARY AND APPROPRIATE for rehabilitative therapy when all of the following criteria are met:
II. Continued Treatment
Continued treatment may be considered MEDICALLY NECESSARY AND APPROPRIATE when all of the following criteria are met:
III. Discharge Criteria
Continuing treatment is considered NOT MEDICALLY NECESSARY when any of the following criteria are met:
IV. Not Medically Necessary
The following are considered NOT MEDICALLY NECESSARY:
V. Experimental/Investigative
Chiropractic services performed for non-musculoskeletal conditions including but not limited to the following are considered EXPERIMENTAL/INVESTIGATIVE due to a lack of clinical evidence demonstrating an impact on improved health outcomes:
Documentation Submission:
Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization when prior authorization is required. In addition, the following documentation must also be submitted:
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
