Chiropractic Guidelines

Covered: chiropractic care is medically necessary only for neuromusculoskeletal conditions with a direct therapeutic link to the treated region that address documented, quantified deficits in Activities of Daily Living and are expected to produce measurable functional improvement; excluded are maintenance/preventive care, non‑neuromusculoskeletal disorders, treatment without quantified ADL deficits or after a plateau, care exceeding reasonable frequency/duration, services that replace needed medical care, and unsupported retrospective requests (for Medicare, treatment must be spinal manipulation to correct a subluxation demonstrated by x‑ray or physical exam). Key requirements: submission must document current condition and quantified ADL deficits using standardized tools (e.g., NDI, ODI, LEFS, PSFS), show red flags were addressed, justify continuation by exacerbation or quantified significant improvement (meeting/exceeding MCID/MDC), and meet authorization timeframes.