The version of this policy will become effective 05/18/2020.
The intent of this policy has not changed, although it has been modified to remove Maintenance Therapy as a benefit contract exclusion.
Diagnosis codes have been deleted from the policy.
The following CPT codes have been deleted from this policy: 97124, 97140, and 97010.
The following modifiers have been deleted from this policy:
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Chiropractic spinal manipulation under anesthesia (MUA) is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.
NOT MEDICALLY NECESSARY
The continued treatment of an individual when the maximum therapeutic goals of a treatment plan have been achieved and no additional functional improvement is apparent or expected to occur, sometimes referred to as maintenance therapy, is considered not medically necessary, and therefore, not covered because the provision of services cease to be of therapeutic value.
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agency, other health care professionals, therapies, and test reports.
Proper documentation in the medical record is the treating provider's responsibility and extends beyond an internal office communication. Specifically, any trained health care provider should be able to review a medical record and clearly understand the status of an individual on a visit-to-visit basis, his/her diagnosis, treatment plans, therapeutic goals, medical necessity or appropriateness of the treatment being rendered, and expected outcome from the prescribed plan of care.
The Company may conduct reviews and audits of services provided to our members, regardless of the participation status of the provider. This process will include, but is not limited to, review of all services related to the claim prior to payment and post-payment review/audit of paid claims. Reviews may initially focus on adequate documentation, the proper usage of CPT and Healthcare Common Procedural Coding System (HCPCS) codes according to the appropriate level of service provided, and the utilization of manipulation services. All documentation must be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
S8990 Physical or manipulative therapy performed for maintenance rather than restoration
AT Acute Treatment
Policy: 03.00.06r:Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
Policy: 03.00.08e:Modifiers XE, XS, XP, XU, and 59
Policy: 07.08.01f:Non-Surgical Spinal Decompression Therapy
Policy: 10.03.01l:Physical Medicine, Rehabilitation, and Habilitation Services