UM Guidelines
Chiropractic Manipulation

Ambulatory Care (AC)

BCBST modification effective December 10, 2013*


Added
   

See hyperlink below to BCBST Medical Policy Manual regarding the following procedures:

Nerve Conduction Studies

Acupuncture

Interferential Current Stimulation

Piezoelectric Sensor Analysis and Oscillating Force Delivered Vertebral Adjustment in the Evaluation and Treatment of the Spinal Column

Somatosensory Evoked Potentials (Non-intraoperative)

Mechanized Axial Spinal Distraction Therapy Devices

Nonoperative Diagnostic Spinal Ultrasound (Echography/Sonogram)

Surface EMG

Manipulation of Musculoskeletal System Under Anesthesia (General, Mild Sedation and Local)

Light Emitting Diode (LED) Therapy

Dynamic Spinal Visualization

Background

Chiropractic / Osteopathic manipulative therapy involves the conservative management of neuromusculoskeletal disorders and related functional clinical conditions. This therapy utilizes both diagnostic and therapeutic procedures; these include, but are not limited to, diagnostic imaging and therapeutic modalities (e.g., manual, mechanical and electrical). This involves adjustment and manipulation of the articulations and adjacent tissues of the human body, primarily of the spinal column.

Definitions

Preventive / Maintenance therapy = Treatment for a patient who has no present pain or symptoms above their normal baseline but seeks to prevent pain /disability, promote health, and enhance quality of life. A preventive / maintenance program consists of activities that preserve the patient's present level of function and prevent regression below their functional baseline. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Therapy / treatment used to delay or minimize deterioration for patients suffering a chronic condition in the absence of exacerbation (e.g., osteoarthritis, fibromyalgia) is also considered to be maintenance therapy. Preventive / maintenance care is not therapeutically necessary.

Palliative Care = Treatment given in the absence of disease or injury only for the temporary & immediate relief of pain that is not restorative to function.

Supportive Care = Treatment for patients who have reached maximum improvement, but fail to sustain this improvement and progressively deteriorate when treatment is withdrawn.

Clinical Indications for Procedure

See algorithms under Appropriateness Determination section V for specific visit guidelines.

  • Spinal manipulation therapy may be indicated when ALL of the following are present:

    • Documentation includes ANY ONE of the following:
      • Services are performed by or under the direct supervision of a licensed Doctor of Chiropractic Medicine (DC) or Doctor of Osteopathy (DO).
      • A certified Chiropractic Therapy Assistant, under the direct supervision of a qualified DC, or a Certified Medical / Physical Therapy Assistant under the direct supervision of a qualified DO, may render services. The DC / DO must be physically present in the facility and actively involved in the treatment.  Refer to the medical policy Staff Supervision Requirements for Delegated Services for further information regarding BCBST's supervision requirements.
    • Treatment and/or manipulative services rendered by a practitioner must be due to a significant health problem in the form of a neuromusculoskeletal condition and have a direct therapeutic relationship to the patient's condition.
    • The patient's medical record including ALL of the following necessary components:
      • Dr./Clinic identification
      • Patient identification
      • Initial patient information
      • Patient demographics, sex and occupation
      • Health history with dates, comorbid conditions, description
      • Review of systems, treatment rendered
      • Exam/Diagnostic findings (must specify diagnostic test/imaging performed)
      • Clinical impressions
      • Progress notes
      • Clinical information
      • Adjustment/Manipulation information
      • All services require initials (written or electronic) identifying anyone rendering services other than attending DC / DO
      • Re-examination / Re-assessment
      • Records must be clear and legible
      • Attending DC / DO should at minimum sign all evaluations/reevaluations
    • Reasonable expectation of significant improvement in the patient's condition / function within a predictable period of time
    • Services must be considered acceptable standards of medical practice that are specific to the treatment of the patient's condition
    • Patient must be making reasonable progress toward therapy goals
    • Services rendered should include instructions on safety precautions & home program
    • Manipulative services must be restorative (i.e., improve function) & supported by documentation in the medical record
    • Absence of services considered (Limitations - services not covered) including ALL the following:
      • Palliative therapy, in the absence of disease or injury, that is not restorative to function
      • Enhancement treatment that is designed to return a patient to a level above their baseline before disease or injury
      • Preventive/Maintenance Care is considered treatment for a patient who has no present pain or symptoms above their normal baseline but seeks to prevent pain and disability, promote health and enhance the quality of life. Maintenance therapy may also be used to delay or minimize deterioration in chronic disease.
      • A preventive/maintenance program consists of activities that preserve the patient's present level of function & prevent regression below their functional baseline. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Therapy / treatment required to delay or minimize deterioration for patients suffering a chronic disease (e.g., osteoarthritis, fibromyalgia) in the absence of exacerbation should also be considered maintenance therapy.
      • Visits for education only, should be completed in 1 to 2 visits per disease process
      • Duplicate services provided simultaneously by a chiropractor and a physical therapist for the same problem
      • Modalities NOT appropriate as part of patient care include, but are not limited to ALL of the following:
        • Hot & Cold packs used in the absence of associated modalities / manipulation
        • Iontophoresis (See hyperlink to medical policies on 1st page)
        • Mechanized Axial Spinal Distraction Therapy Devices (See hyperlink to medical policies on 1st page)
        • Surface EMGS (See hyperlink to medical policies on 1st page)
        • Manipulation of Musculoskeletal System Under Anesthesia (General, Mild Sedation and Local) (See hyperlink to medical policies on 1st page)
        • Massage therapy if not performed in conjunction (immediately before or after) with manipulation
      • Relative Contraindications which include, but are not limited to, ALL of the following:
        • Bleeding disorder & anticoagulant therapy
        • Radiculopathy with progressive neurological signs
        • Severe demineralization of bone
        • Articular hyper mobility & circumstances where stability of the joint is uncertain
      • Absolute Contraindications which include, but are not limited to, ALL of the following:
        • Acute arthropathies with inflammation & ligamentous laxity & anatomic subluxation or dislocation;
        • including acute rheumatoid arthritis & ankylosing spondylitis
        • Acute fractures & dislocations or healed fractures & dislocations with signs of instability
        • Unstable os odontoideum
        • Malignancies involving the vertebral column
        • Infection of bones or joints of vertebral column
        • Signs & symptoms of myelopathy or cauda equina syndrome
        • Cervical spinal manipulations, vertebrobasilar insufficiency syndrome
        • Significant major artery aneurysm near the proposed manipulation

Treatment Plan - Assessment Requirements (Evaluation & Plan of Care)

Treatment plan includes:
  • Initial Evaluation includes ALL of the following:
    • Patient history
    • Physical examination
    • Pain assessment
    • Prior interventions & treatments
    • Diagnostic imaging
    • Primary diagnosis
    • Date of onset
    • Date of diagnosis
    • Baseline status
    • Functional potential
    • Current functional abilities
    • Muscle strength
    • ROM abnormality
    • Circulation & sensation
    • Other therapies, treatments, physical therapy
    • Medical compliance
    • Patient's goals
  • Plan of Care includes ALL of the following:
    • Long & short-term goal
    • Discharge goals
    • Measurable objectives
    • Functional objectives
    • Time frame (frequency & duration of treatment)
    • Date therapy to begin
    • Specific modalities, therapy, exercise
    • Safety & preventive education
    • Home program

Appropriateness Determination

  • A limited number of visits should be approved for the first 4 weeks. Refer to algorithms below for frequency/duration of visits.

  • Greater than 3 visits per week is seldom justified, exceptions (e.g., the first week of treatment for pain with complications, may require 5 visits) must be based on a review of the practitioner’s documentation.

  • Extension requires reevaluation. Evaluation should occur after the initial 4 weeks of treatment & include the following:
    • Subjective Progress (e.g., reduction in pain, compliance)
    • Objective Progress (e.g., structural exam, notation of lesions, ROM, functional improvement)
    • Progress toward treatment goals
    • Additional treatment required to reach treatment goals
    • Discharge plans
    • Discharge date
Frequency & Duration of Care Algorithms

Algorithm 1 - Acute Uncomplicated Pain

  • This algorithm applies to patients with acute pain for 3 weeks or less.
  • Provides for 3 treatments a week for 4 weeks. A reexamination must be performed every two weeks after treatment is initiated. If there is no documented improvement within 2 weeks, treatment should be modified or the patient referred to another medical professional for a second opinion.
  • 3 therapy modalities with associated manipulation per visit may be required during the first week of treatment for acute pain. Thereafter, only 2 therapy modalities with associated manipulation are allowed per visit.
  • Typically such a patient is treated up to 3 times weekly for 2 weeks, then 3 times to 1 time weekly during the next 2 weeks depending upon progress, re-injury, etc. This amounts to 8-12 treatments over a 4-week period.
  • If there is documented improvement (e.g., decreased pain on pain scale, objective measures of range of motion and pressure tenderness) treatment may continue for up to another 4 weeks (for a total of 8 weeks of treatment). Frequency of care should drop to 1 to 2 visits per week.

Algorithm 2 - Acute/Chronic Pain with Complications

  • This algorithm applies to patients with acute pain and complications (e.g., significant trauma, severe pain, significant underlying spinal degeneration, a disc problem with referred pain to the leg, etc.) or recurring or chronic pain, or the most recent of several disabling attacks of spinal pain, or the back pain/shoulder pain/headache/leg pain that has been experienced over many weeks or months.
  • Treatment may be slightly more frequent than Algorithm 1. Typically treatment is 5 times a week for the first week then 3 times a week for the next 3-5 weeks, then 2 times weekly thereafter for another 4-6 weeks (for a total of 8-12 weeks of treatment). Many patients can expect a successful result within 4-6 weeks. A reexamination must be performed every two weeks after treatment is initiated.
  • 3 therapy modalities with associated manipulation per visit may be required during the first week of treatment for acute pain. Thereafter, only 2 therapy modalities with associated manipulation are allowed per visit.

Note: In rare instances a longer treatment duration than 12 weeks may be needed; these instances will need to be evaluated/approved on a case by case basis.

Algorithm 3 - Supportive Care

  • The U.S. and Canadian national guidelines for chiropractic practice define two different forms of longer term chiropractic treatment:
    • Supportive Care – Treatment for patients who have reached maximum improvement, but who fail to sustain this improvement and progressively deteriorate when treatment is withdrawn. (Note: Supportive care is necessary from the patient’s and physician’s point of view.)
      • Typically supportive care might involve 3-6 treatments over 2 weeks to arrest returning pain and disability, then 1 treatment every 2-4 weeks for a settling period of a few months and another attempt at complete withdrawal of care.
    • Preventive/Maintenance Care – Treatment for a patient who has no present pain or symptoms but seeks to prevent pain and disability, promote health and enhance the quality of life. (Note: Preventive/maintenance care is not therapeutically necessary.)

Footnote

A preventive / maintenance program consists of activities that preserve the patient's present level of function and prevent regression below their functional baseline. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Therapy / treatment used to delay or minimize deterioration for patients suffering a chronic condition in the absence of exacerbation (e.g., osteoarthritis, fibromyalgia) is also considered to be maintenance therapy.

References

BlueCross BlueShield of Tennessee network physicians. September - December 2013.