Coverage Explanation

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)

The following is chiropractic benefit information for Medicare-covered services and routine services (not covered by Original Medicare).

Chiropractic Services as Medical Benefits (Original Medicare Chiropractic Coverage)

Medicare Advantage (MA) HMO members have coverage for Original Medicare-covered chiropractic benefits of manual manipulation of the spine to correct subluxation of an acute condition. Prior authorization may be required, except in an emergency. Maintenance care is not considered by Medicare to be medically reasonable and necessary, and is not covered. For MA PPO members, authorization is not required for out-of-network services; however, the services must meet the requirements indicated in the Coverage Criteria section. Enrollees may also self-refer for out-of-network coverage.

Health Net and its delegated participating physician groups (PPGs) apply Medicare's coverage criteria when determining whether a referral to a chiropractor (or equivalent manipulative practitioner) is warranted.

A chiropractor may use an X-ray or other diagnostic test, performed for diagnostic purposes, to demonstrate medical necessity before commencing treatment; however, these diagnostic tests or X-rays are not covered when ordered, taken or interpreted by a chiropractor. Therefore, if the existence of subluxation is not known, an evaluation to determine subluxation should be considered prior to issuing a denial of chiropractic treatment.

Coverage for chiropractic services is limited to those services performed by a doctor of chiropractic, osteopathy or medicine licensed by the state of California.

Coverage Criteria

The primary diagnosis for chiropractic coverage must be subluxation. Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact. A subluxation may be demonstrated by an X-ray or physical examination.

Chiropractors must use the acute treatment (AT) modifier when billing chiropractic claims (CPT codes 98940, 98941, 98942) to identify services that are active/corrective treatment of acute or chronic subluxation, which are covered Original Medicare benefits.

Physical therapy is not equivalent therapy. Physical therapists cannot perform manual manipulation of the spine, which is the extent of Original Medicare-covered chiropractic services covered under the member's medical benefits.

Routine Chiropractic Services (Non-Medicare Covered Services) for MA HMO

Coverage for routine chiropractic services (non-Medicare covered services) is available to some Health Net HMO Medicare Advantage (MA) members as part of the Optional Supplemental Benefits Package or in some plans as a core supplemental benefit. Employer groups may purchase additional chiropractic care benefits through American Specialty Health Plans, Inc. (ASH Plans). All members with supplemental coverage must obtain routine services through ASH Plans' network of contracting chiropractors in accordance with the requirements of the Optional Supplemental Benefits Package.