Chiropractic Guidelines

Chiropractic services (CMT, E/M, modalities, therapeutic procedures) are covered only when reasonable and necessary for neuromusculoskeletal conditions to restore lost function and are excluded if maintenance/preventive, non‑neuromusculoskeletal, duplicated, without quantified ADL deficits or documented improvement, excessive in frequency/duration, for sport/performance without ADL deficits, or provided in the presence of red‑flag/life‑threatening conditions or to replace/delay other necessary care. Key requirements: documentation must show the specific procedure was performed on the date of service using the most specific CPT, support all units billed (with face‑to‑face/time rules for time‑based services), include quantified functional loss and standardized measures (MCID/MDC) to justify initiation/continuation, and for Medicare specifically document manual spinal manipulation correcting a subluxation demonstrated by x‑ray or physical exam.

"Chiropractic Services considered medically necessary are those that are reasonable and necessary, based on Generally Accepted Standards of Practice, for the evaluation, diagnosis, and treatment of ..."