Aetna considers chiropractic services medically necessary when all of the following criteria are met:
- The member has a neuromusculoskeletal disorder; and
- The medical necessity for treatment is clearly documented; and
- Improvement is documented within the initial 2 weeks of chiropractic care.
If no improvement is documented within the initial 2 weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified.
If no improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary.
Once the maximum therapeutic benefit has been achieved, continuing chiropractic care is considered not medically necessary.
Chiropractic manipulation in asymptomatic persons or in persons without an identifiable clinical condition is considered not medically necessary.
Chiropractic care in persons, whose condition is neither regressing nor improving, is considered not medically necessary.
Manipulation is considered experimental and investigational when it is rendered for non-neuromusculoskeletal conditions (e.g., attention-deficit hyperactivity disorder, dysmenorrhea, and epilepsy; not an all inclusive list) because its effectiveness for these indications is unproven.
Manipulation of infants is considered experimental and investigational for non-neuromusculoskeletal indications.
Chiropractic manipulation has no proven value for treatment of idiopathic scoliosis or for treatment of scoliosis beyond early adolescence, unless the member is exhibiting pain or spasm, or some other medically necessary indications for chiropractic manipulation are present.
Please note: Some plans have limitations or exclusions applicable to chiropractic care. Please check benefit plan descriptions for details.
Also check the list of all CPT / HCPCS codes to report Chiropractic services