Chiropractic Guidelines

Covered: eviCore authorizes chiropractic exams, spinal manipulation, adjunctive physiotherapy and emergency chiropractic services for neuromusculoskeletal cervical conditions when medically necessary, and excludes non‑participating/non‑authorized services, care outside the plan, maintenance/preventive care, TMJ/MUA, most routine advanced diagnostics, workers’‑comp/auto‑covered injuries, experimental treatments and services exceeding benefit limits. Key requirements: pre-authorization and documentation of significant functional limitation and pain ≥3/10 using validated measures (e.g., NDI/ODI), staged conservative management with specified improvement benchmarks/timelines, radiographs/advanced testing only if medically necessary, and immediate medical evaluation/referral for red flags or lack of expected progress.

"Cervical (Non-Specific): Cervical Nonallopathic Lesion — M99."