Indications and Limitations of Coverage and/or Medical Necessity
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.
Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient's symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient's clinical presentation. Failure of the patient's symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.
This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per month and 30 chiropractic manipulation services per beneficiary per year. Despite allowing up to these maximums, each patient's condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient's medical record.
Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:
- Twelve (12) chiropractic manipulation treatments for Group A diagnoses.
- Eighteen (18) chiropractic manipulation treatments for Group B diagnoses.
- Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses.
- Thirty (30) chiropractic manipulation treatments for Group D diagnoses.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.
As published in CMS IOM, Pub. 100-08, Section
13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient's medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient's medical needs.
- At least as beneficial as an existing and available medically appropriate alternative.
CMS National Coverage Policy:
This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for chiropractic services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for chiropractic services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding chiropractic services are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
- Medicare Benefit Policy Manual - Pub. 100-2, Chapter 15, Section 30.5, Section 240.1.3.
- Medicare National Coverage Determinations Manual - Pub. 100-03.
- Correct Coding Initiative - Medicare Contractor Beneficiary and Provider Communications Manual - Pub. 100-09, Chapter 5.
- Social Security Act (Title XVIII) Standard References, Sections:
- 1862 (a)(1)(A) Medically Reasonable & Necessary.
- 1862 (a)(1)(D) Investigational or Experimental.
- 1833 (e) Incomplete Claim.
Jurisdiction "H" Notice:
Jurisdiction "H" comprises the states of Arkansas, Louisiana, Mississippi, Colorado, New Mexico, Oklahoma, and Texas. Novitas is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (8/13/2012 - 11/19/2012); and, is a consolidation of the previous legacy contractors' policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination.
| ST | Legacy A
Contractor
&
Contract Number | Legacy B
Contractor
&
Contract Number | J "H" MAC A
Contractor
&
Contract Number | J "H" MAC B
Contractor
&
Contract Number | J "H"
Effective
Date |
|---|
| AR | | PBSI: 00520 (J7) | | Novitas: 07102 | 08/13/12 |
| LA | | PBSI: 00528 (J7) | | Novitas: 07202 | 08/13/12 |
| AR | PBSI: 00020 (J7) | | Novitas: 07101 | | 08/20/12 |
| LA | PBSI: 00233 (J7) | | Novitas: 07201 | | 08/20/12 |
| MS | PBSI: 00233 (J7) | | Novitas: 07301 | | 08/20/12 |
| MS | | Cahaba: 00512 (J7) | | Novitas: 07302 | 10/22/12 |
J 4
States | Trailblazer: 04901 | | Novitas: 04911 | | 10/29/12 |
| CO | Trailblazer: 04101 | | Novitas: 04111 | | 10/29/12 |
| NM | Trailblazer: 04201 | | Novitas: 04211 | | 10/29/12 |
| OK | Trailblazer: 04301 | | Novitas: 04311 | | 10/29/12 |
| TX | Trailblazer: 04401 | | Novitas: 04411 | | 10/29/12 |
| CO | | Trailblazer: 04102 | | Novitas: 04112 | 11/19/12 |
| NM | | Trailblazer: 04202 | | Novitas: 04212 | 11/19/12 |
| OK | | Trailblazer: 04302 | | Novitas: 04312 | 11/19/12 |
| TX | | Trailblazer: 04402 | | Novitas: 04412 | 11/19/12 |
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