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Cigna Medical Coverage Policy- Therapy ServicesChiropractic CareEffective Date: 12/15/2021Next Review Date: 12/15/2022INSTRUCTIONS FOR USECigna / ASH Medical Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered byCigna Companies. Please note, the terms of a customer’s particular benefit plan document may differ significantly from the standardbenefit plans upon which these Cigna / ASH Medical Coverage Policies are based. In the event of a conflict, a customer’s benefit plandocument always supersedes the information in the Cigna / ASH Medical Coverage Policy. In the absence of a controlling federal orstate coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Determinations in eachspecific instance may require consideration of:1) the terms of the applicable benefit plan document in effect on the date of service2) any applicable laws/regulations3) any relevant collateral source materials including Cigna-ASH Medical Coverage Policies and4) the specific facts of the particular situationCigna / ASH Medical Coverage Policies relate exclusively to the administration of health benefit plans.Cigna / ASH Medical Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines.Some information in these Coverage Policies may not apply to all benefit plans administered by Cigna. Certain Cigna Companiesand/or lines of business only provide utilization review services to clients and do not make benefit determinations. References to standardbenefit plan language and benefit determinations do not apply to those clients.Coverage for chiropractic care varies across plans. Refer to the customer’s benefit plan document forcoverage details.When covered, chiropractic care may be subject to the terms, conditions and limitations of theapplicable benefit plan’s Short-Term Rehabilitative Therapy or Chiropractic Care Services benefit andschedule of copayments. Chiropractic care provided to treat an injury or condition that is work-relatedor was sustained in the workplace may require coordination of benefits (COB). Please refer to theapplicable benefit plan document to determine the terms, conditions and limitations of coverage.If coverage for chiropractic care is available, the following conditions of coverage apply.GUIDELINESMedically NecessaryI. Chiropractic services are considered medically necessary when ALL of the following conditions aremet:Chiropractic Care (CPG 278)Page 1 of 30

The service is aimed at diagnosis, and treatment of musculoskeletal and related disorders and theeffects of these on the nervous system and general healthThe service is for conditions that require the unique knowledge, skills, and judgment of a chiropractor foreducation and training that is part of an active skilled plan of treatmentThe program is individualized, and there is documentation outlining quantifiable, attainable treatmentgoals.The individual’s condition has the potential to improve or is improving (and has not reached maximumimprovement).Improvement is evidenced by successive objective measurements over a defined time frame.The services are delivered by a qualified provider of chiropractic servicesII. Upper extremity manipulation/mobilization is considered medically necessary as part of a multimodaltreatment program for shoulder complaints, dysfunction, disorders and/or pain. Ifexamination/evaluation of any other UE condition indicate restricted joint play, addition ofmanipulation/mobilization with standard care is reasonable.III. Use of lower extremity manipulation/mobilization is considered medically necessary as part of amultimodal treatment of ankle inversion sprains. If examination/evaluation of any other LE conditionindicate restricted joint play, addition of manipulation/mobilization with standard care is reasonable.IV. Supportive care, also referred to as ongoing care, or long-term treatment or care, may be necessaryas a treatment for individuals who have reached a maximum benefit but fail to sustain the benefit andprogressively deteriorate when removed from treatment programs. The potential for the individual todevelop dependency on ongoing care should be considered in treatment planning. Once a maximumbenefit has been reached, continuing chiropractic care is considered not medically necessary.Not Medically NecessaryI.Chiropractic services are considered not medically necessary if any of the following isdetermined: Chiropractic services are considered maintenance /preventive: Maintenance/preventive care is defined as elective healthcare that is typically long-term, bydefinition not therapeutically necessary, but provided at intervals (preferably regular) toprevent disease, promote health and enhance the quality of life. Ongoing preventive/maintenance care may include patient education, screening proceduresto identify risk, a home exercise program (HEP), and lifestyle modifications in the hope ofpromoting optimal health. The service is not aimed at diagnosis, and/or treatment of disorders of the musculoskeletal system,and the effects of these disorders on the nervous system and general health. The service is for conditions for which therapy would be considered routine educational, training,conditioning, or fitness. This includes treatments or activities that require only routine supervision. The service(s) are not expected to result in a practical improvement in the level of functioning withina reasonable and predictable period of time. The documentation fails to objectively verify functional progress over a reasonable period of time. Improvement or restoration of function could reasonably be expected as the individual graduallyresumes normal activities without the provision of skilled therapy services. For example:1. An individual suffers a transient and easily reversible loss or reduction in functionwhich could reasonably be expected to improve spontaneously as the individualgradually resumes normal activities;2. A fully functional individual who develops temporary weakness from a period of bedrest. Chiropractic services that do not require the skills of a qualified provider of chiropractic services.Examples include but not limited to: Activities for the general good and welfare of the individual:1. General exercises (basic aerobic, strength, flexibility or aquatic programs) topromote overall fitness/conditioningChiropractic Care (CPG 278)Page 2 of 30

2. Services/programs for the primary purpose of enhancing or returning to athletic orrecreational sports.3. Massages and whirlpools for relaxation4. General public education/instruction sessions Activities and services that an individual can practice independently and can be selfadministered safely and effectively:1. Activities that require only routine supervision and NOT the skilled services of achiropractor2. When a home exercise program is sufficient and can be utilized to continue therapy(examples of exceptions include but would not be limited to the following: if individualhas poor exercise technique that requires cueing and feedback, lack of support athome if necessary for exercise program completion, and/or cognitive impairmentthat doesn’t allow the individual to complete the exercise program)The physical medicine and rehabilitation modalities are not preparatory to other skilled treatmentprocedures or are not necessary in order to safely and effectively provide other skilled treatmentprocedures.Modalities that have been deemed to provide minimal to no clinical value independently or within acomprehensive treatment for any condition and/or not considered the current standard of care withina treatment program Infrared light therapy Vasopneumatic deviceTreatments/services that are not supported in peer-reviewed literature and not performed inaccordance with this and other applicable standards of practice and clinical practice guidelines ormedical policies.Services provided to reduce potential risk factors where significant improvement is not expectedUse of upper extremity manipulation/mobilization as a part of multimodal treatment program forepicondylitis/epicondylalgia and carpal tunnel syndrome. In the absence of contraindications and if examination/evaluation suggest additionalfindings indicating manipulation/mobilization of UE joints in addition to standard care maybe beneficial (e.g., restricted joint play of humeroradial joint, restricted joint play ofradiocarpal joint), use of these interventions is reasonable.Use of lower extremity manipulation/mobilization combined with multimodal treatment program for thetreatment of hip osteoarthritis, knee osteoarthritis, and/or plantar fasciitis. In the absence of contraindications and if examination/evaluation suggest additional findingsindicating manipulation/mobilization of LE joints in addition to standard care may be beneficial(e.g., restricted joint play of iliofemoral joint, restricted joint play of the proximal tibiofibularjoint)), use of these interventions is reasonable.II.The following treatments are considered not medically necessary because they are nonmedical,educational or training in nature. In addition, these treatments/programs are specificallyexcluded under many benefit plans: back school vocational rehabilitation programs and any program with the primary goal of returning anindividual to work work hardening programsIII.Duplicative or redundant services expected to achieve the same therapeutic goal are considerednot medically necessary. For example: Multiple modalities procedures that have similar or overlapping physiologic effects (e.g., multipleforms of superficial or deep heating modalities) Same or similar rehabilitative services provided as part of an authorized therapy programthrough another therapy discipline. When an individual receives rehabilitation from a physical therapist, occupational therapist,chiropractor or other rehabilitation professional, each practitioner should provide differenttreatments that reflect each discipline's unique perspective on the individual's impairmentsand functional deficits and not duplicate the same treatment. They must also have separateevaluations, treatment plans, and goals. When an individual receives manual therapy servicesChiropractic Care (CPG 278)Page 3 of 30

from a physical therapist and chiropractic or osteopathic manipulation, the services must bedocumented as separate and distinct and must be justified as non-duplicative. The medical necessity of neuromuscular reeducation, therapeutic exercises, and/ortherapeutic activities, performed on the same day, must be documented in the medical record.Experimental, Investigational, UnprovenChiropractic manipulation and adjunct therapeutic procedures/modalities (e.g., mobilization, therapeuticexercise, traction) for treatment of non-musculoskeletal conditions are considered experimental,investigational or unproven.Use of any of the following treatments are considered experimental, investigational or unproven: Dry hydrotherapy/aquamassage/hydromassage Non-invasive Interactive Neurostimulation (e.g., InterX ) Microcurrent Electrical Nerve Stimulation (MENS) H-WAVE Elastic therapeutic tape/taping (e.g., Kinesio tape, KT TAPE/KT TAPE PRO , Spidertech tape) Dry Needling Low-level laser therapy (LLLT) Vertebral axial decompression therapy and devices (e.g., VAX-D, DRX, DRX2000, DRX3000,DRX5000, DRX9000, DRS, Dynapro DX2, Accu-SPINA System, IDD Therapy [Intervertebral Differential Dynamics Therapy], Tru Tac 401, Lordex Power Traction device,Spinerx LDM) MedX lumbar/cervical machines Cybex back system/Biodex Digital radiographic mensuration Digital postural analysis Thermography Spinal/paraspinal ultrasound Surface electromyography /paraspinal electromyography Iontophoresis or phonophoresisMassage TherapyMassage therapy is considered NOT medically necessary when it is provided in the absence of othercovered chiropractic modalities or physical therapy/occupational therapy. It must be provided as part ofa multi-modal rehabilitation program.Note: Massage therapy may be provided by several types of providers. To qualify for coverage, the providermust meet the definition of provider contained in the benefit plan. Please refer to the applicable plan language todetermine benefit coverage for the rendering provider.Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and thenervous system, and the effects of these disorders on general health. Chiropractic services are used most oftento treat musculoskeletal and related conditions. Chiropractic services are intended to improve, adapt or restorefunctions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, orcongenital abnormality involving goals an individual can reach in a reasonable period of time Benefits will endwhen treatment is no longer medically necessary and the individual stops progressing toward those goals. Thespecific time frames for which one would expect practical functional improvement is dependent on variousfactors. A reasonable trial of care for chiropractic services is generally 2-8 weeks and is influenced by thediagnosis; clinical evaluation findings; stage of the condition (acute, sub-acute, chronic); severity of thecondition; and patient-specific findings (age, gender, past and current medical history, family history, and anyrelevant psychosocial factors).Chiropractic Care (CPG 278)Page 4 of 30

Chiropractic care may be a primary method of treatment for some medical conditions, such as lower back pain,or may complement or support medical treatment for other conditions by relieving the musculoskeletal aspectsassociated with the condition. Chiropractors may refer patients to the appropriate health care provider whenchiropractic care is not suitable for the patient’s condition, or the condition warrants co-management inconjunction with other health care providers.Spinal manipulation (sometimes referred to as a "chiropractic adjustment") is a common, therapeutic procedureperformed by doctors of chiropractic. The purpose of spinal manipulation is to restore joint mobility by manuallyapplying a controlled force into joints that have become hypomobile, or restricted in their movement, as a resultof a tissue injury. Tissue injury can be caused by a single traumatic event or through repetitive stresses. Ineither case, injured tissues undergo physical and chemical changes that can cause inflammation, pain, anddiminished function. Manipulation, or adjustment of the affected joint and tissues, restores mobility, therebyalleviating pain and muscle tightness allowing tissues to heal. In addition to manual therapy otherprocedures/modalities, both passive and active, are often used as adjunct treatments throughout the treatmentprogram.GENERAL BACKGROUNDChiropractic spinal manipulation requires professional skills to identify spinal segmental joint dysfunctioncharacterized by altered joint alignment, motion, or physiologic function in an intact spinal motion segment. Theprimary objectives of chiropractic spinal manipulation are to alleviate musculoskeletal pain, muscle spasm, andfunctional impairment of the spine. This form of manipulation is a therapeutic procedure characterized bycontrolled force, leverage, direction, amplitude, and velocity (directional, high velocity, low amplitude thrust)(Peterson & Bergmann, 2002).Response to chiropractic treatment typically occurs within two to eight weeks. The medical necessity of continuedchiropractic care is dependent on documented progress toward therapeutic goals. Maximum therapeutic benefithas been reached when the patient fails to show improvement, or when a pre-injury level of functioning has beenreached. Chiropractic physicians should document in clinical records the objective findings and subjectivecomplaints that support the necessity for a chiropractic treatment regimen. A treatment plan should be developedwith planned procedures/modalities (frequency and duration), measurable and attainable short- and long-termgoals, and anticipated duration of care. At a minimum, documentation is required for every treatment day and foreach area or spinal segment treated and for each therapy performed. Each daily record should include: the dateof service, the total treatment time for each date of service, and the identity of the person(s) providing the services;the type and specific location of CMT including segment(s) adjusted, subluxation listings/dynamic restrictions,direction(s) of corrective thrust(s), and specific technique(s) used; the name of each modality and/or procedureperformed, the parameters for each modality (e.g., amperage/voltage, location of pads/electrodes), area oftreatment, and total treatment time spent for each therapy (mandatory for timed services). Failure to properlyidentify and sufficiently document the parameters for each therapy on a daily progress note may result in anadverse determination (partial approval or denial).There should be a reasonable expectation that the identifiedgoals will be met. The following are recommended: If conservative care is appropriate, a short course (not to extend beyond eight weeks) is warranted.If the patient demonstrates objective evidence of improvement, additional care may be appropriate. The provider should attempt to integrate some form of active care as early as possible. Continueduse of passive care modalities may lead to patient dependency and should be avoided. Passive modalities may be helpful for short term relief of the acute signs of inflammation (e.g., pain,muscle spasm, swelling, loss of function). The utilization of passive modalities is not consideredmedically necessary once the acute phase of care is over. The utilization of more than 2 passive modalities per office visit is typically considered excessive andis not supported as medically necessary. Use of more than 2 modalities on each visit date should bejustified in the documentation. These rules hold true for acute, chronic and postsurgical cases. No matter what specific treatment ischosen, it must yield identifiable, objective outcomes to establish the necessity of care.Duplicated / Insufficient Information(1) Entries in the medical record should be contemporaneous, individualized, appropriately comprehensive, andmade in a chronological, systematic, and organized manner. Duplicated/nearly duplicated medical records (a.k.a.Chiropractic Care (CPG 278)Page 5 of 30

cloned records) are not acceptable. It is not clinically reasonable or physiologically feasible that a patient’scondition will be identical on multiple encounters. (Should the findings be identical for multiple encounters, itwould be expected that treatment would end because the patient is not making progress toward current goals.)This includes, but not limited to: duplication of information from one treatment session to another (for the same or different patient[s]); duplication of information from one evaluation to another (for the same or different patient[s]).Duplicated medical records do not meet professional standards of medical record keeping and may result in anadverse determination (partial approval or denial) of those services.(2) The use of a system of record keeping that does not provide sufficient information (e.g., checking boxes,circling items from lists, arrows, travel cards with only dates of visit and listings) should not be submitted. Thesetypes of medical record keeping may result in an adverse determination (partial approval or denial) of thoseservices.Effective and appropriate documentation that meets professional standards of medical record keeping thatadequately detail a proper assessment of the patient’s status, the nature and severity of patient complaint(s) orcondition(s), and/or other relevant clinical information (e.g., history, parameters of each therapy performed,objective findings, progress towards treatment goals, response to care, prognosis.) is expected.Modalities and ProceduresIn some states, Chiropractic physicians are required to hold a specific certification to use physical medicinemodalities in practice. The American Medical Association (AMA) Current Procedural Terminology (CPT) manualdefines a modality as "any physical agent applied to produce therapeutic changes to biologic tissue; includes butis not limited to thermal, acoustic, light, mechanical, or electric energy” (AMA, 2018). Modalities may besupervised, which means that the application of the modality doesn’t require direct one-on-one patient contact bythe practitioner; or modalities may involve constant attendance, which indicates that the modality requires directone-on-one patient contact by the practitioner. Examples of supervised modalities include application of hot orcold packs, mechanical traction, and unattended electrical stimulation. Examples of modalities that requireconstant attendance include ultrasound, manually applied electrical stimulation, and iontophoresis.Passive modalities are most effective during the acute phase of treatment, since they are typically directed atreducing pain, inflammation, and swelling. They may also be utilized during the acute phase of the exacerbationof a chronic condition. The use of passive modalities are not generally considered medically necessary unlessthey are preparatory and essential to the safe and effective delivery of other skilled treatment procedures (e.g.chiropractic manipulation, therapeutic exercise training, etc.). After one or two weeks, the clinical effectiveness ofpassive modalities begins to decline significantly. The need for passive modalities beyond two weeks should beobjectively documented in the clinical record.The AMA CPT manual defines therapeutic procedures as "A manner of effecting change through the applicationof clinical skills and/or services that attempt to improve function" (AMA, 2018). Examples of therapeutic proceduresinclude therapeutic exercise to develop strength and endurance, range of motion and flexibility; neuromuscularre-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioceptive activities;aquatic therapy; and manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage,manual traction); or therapeutic activities using dynamic activities to improve functional performance (direct oneon-one patient contact by the practitioner).Transition from passive physiotherapy modalities to active treatment procedures should be timely and evidencedin the medical record, including instructions on self/home care. And in most cases, active treatment should beinitiated in addition to modality use at a level that is appropriate for the patient.Active therapeutic procedures are typically started as swelling, pain, and inflammation are reduced. The need forstabilization and support is replaced by the need for increased range of motion and restoration of function. Activecare elements include increasing range of motion, strengthening primary and secondary stabilizers of a givenregion, and increasing the endurance capability of the muscles. Care focuses on active participation of the patientin their exercise program. Activities of Daily Living (ADLs) training, muscle strengthening, movement retraining,and progressive resistive exercises are considered active procedures. In general, patients should progress fromactive procedures to a home exercise program.Chiropractic Care (CPG 278)Page 6 of 30

Certain physical medicine modalities and therapeutic procedures are considered duplicative in nature and it wouldbe inappropriate to perform or bill for these services during the same session, such as: Functional activities and ADLs; More than one deep heating modality; Massage therapy and myofascial release; Orthotics training and prosthetic training; and Whirlpool and Hubbard tank.The medical necessity of neuromuscular reeducation, therapeutic exercises, and/or therapeutic activities,performed on the same day, must be documented in the medical record.Only one heat modality would be considered medically necessary during the same treatment session, with theexception of use of one form of superficial heat and one form of deep heat (i.e., ultrasound or diathermy and hotpacks). Use of two forms of deep or superficial heat would not be acceptable. Hot or cold packs should not beused in the absence of other modalities or manipulation and must be part of a multi-modal rehabilitation program.Exacerbation/Re-injuryAccording to the CCGPP consensus recommendations for the management of chronic spine related conditions,“An exacerbation is characterized by a return of atypical pain and/or other symptoms and/or pain-related difficultyperforming tasks and actions equivalent to the appropriate minimal clinically important change value for theoutcome of interest.” (Farabaugh, et al., 2010). Once maximum therapeutic benefit has been reached anddocumented, additional chiropractic services may be warranted when there is an exacerbation of the condition orre-injury. Management of chronic pain conditions involves an understanding and compliance with self-directedhome care, and when self-directed care fails to sustain previously achieved gains during exacerbation or re-injury,a short course of treatment (i.e., 1-6 visits per episode) may be necessary (Farabaugh, et al., 2010 [Council ofChiropractic Guidelines and Practice Parameters [CCGPP]).The evaluation and documentation of the need for chiropractic services for exacerbation or re-injury should includedetail surrounding the individuals response to previous and current modalities of treatment, response to absenceof treatment, that maximum therapeutic benefit was reached and documented, analgesic pattern use, patientcentered outcome assessment tools, and any other health care services that have been used to managesymptoms (Farabaugh, et al., 2010). Clinical documentation should clearly describe the condition that requiresadditional treatment sessions, and that the condition is an exacerbation or re-injury.DOCUMENTATION GUIDELINESEvaluationAn initial evaluation service is essential to determine whether any services are medically necessary, to gatherbaseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation is usuallycompleted in a single session. An evaluation is needed before implementing any chiropractic treatment. Initialevaluations include an Evaluation and Management (New Patient or Established Patient E/M) service and mayinclude, as necessary, imaging, laboratory studies, and other diagnostic tests and measures. The initial evaluationservice must include: A level of clinical history, examination, and medical decision-making relevant andappropriate to the individual’s complaint(s) and presentation; Prior functional level, if acquired condition; Specific standardized and non-standardized tests, assessments, and tools; Analytic interpretation and synthesis of all data, including imaging studies, special tests, lab reports,and/or reports/records from other healthcare providers; Objective, measurable, and functional descriptions of an individual's deficits using comparable andconsistent methods; Summary of clinical reasoning and consideration of contextual factors with recommendations; The establishment of a working diagnosis; Plan of care with specific treatment techniques or activities to be used in treatment sessions that shouldbe updated as the individual's condition changes; Frequency and duration of treatment (treatment dose); Functional, measurable, and time-framed long-term and short-term goals based on appropriate andrelevant evaluation data; Rehabilitation prognosis and discharge plan.Chiropractic Care (CPG 278)Page 7 of 30

Note: Appropriate range of motion (ROM) testing (CPT codes 95851- 95852) and/or manual muscle testing (MMT)(CPT codes 95831 – 95834), including digital wireless dynamometers and inclinometers or other such electronicdevice that measures strength and/or ROM using a handheld device are integral within Evaluation/Reevaluationcodes. Computerized isokinetic muscle strength and endurance testing using a machine, such as a Biodex, wouldbe considered a physical performance test or measurement using CPT code 97750 – “Physical performance testor measurement (e.g. musculoskeletal, functional capacity), with written report, each 15 minutes.”Treatment SessionsChiropractic treatment can vary from Chiropractic Manipulative Therapy alone (CMT CPT codes 98940-98943) tothe use of a variety of physical medicine and rehabilitation modalities and procedures depending on the patient’scondition, response to care, and treatment tolerance. All services must be supported in the treatment plan and bebased on an individual's medical condition. A chiropractic treatment session may include: Chiropractic Manipulative Therapy (CMT). A brief evaluation of the patient’s progress and response toprevious treatment(s) is included in the work value of a CMT. Passive physical medicine modalities such as electrotherapeutic and mechanical modalities preparatoryto other skilled services Active physical medicine procedures such as therapeutic exercise, including neuromuscular reeducation,coordination, and balance; Functional training in self-care and home management; Functional training in and modification of environments (home, work, school, or community), includingbiomechanics and ergonomics; Manual therapy techniques, including soft tissue mobilization, joint mobilization, and manual lymphaticdrainage; Assessment, design, fabrication, application, fitting, and training in assistive technology, adaptive devices,and orthotic devices; Training in the use of prosthetic devices; Skilled reassessment of the individual's problems, plan, and goals as par

Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic services are used most often to treat musculoskeletal and related conditions. Chiropractic