REASONS FOR DENIAL
* When the number of manipulations exceeds the norm. (This type of denial will
still require a claim be submitted to Medicare.)
* Excluded Services: An excluded service from Medicare coverage is any service
other than manual manipulation for treatment of subluxation of the spine. The
chiropractor is not required to bill excluded services; however, the provider
may bill these services to Medicare to obtain a denial for secondary insurance
purposes. The following are examples (not an all-inclusive list) of services
that, when performed or ordered by the chiropractor, are excluded from Medicare
coverage and for which the beneficiary is responsible for payment:
o Therapy for a chronic condition that does not meet the definition as described
in the “Indications and Limitations and/or Medical Necessity” section of this
policy.
o Laboratory tests.
o X-rays.
o Office visits (history and physical).
o Physical therapy.
o Supplies.
o Injections.
o Drugs.
o Acupuncture.
o Orthopedic devices.
o Nutritional supplements/counseling.
o Any service ordered by the chiropractor.
* Any manipulation, including low-force technique, where one of the absolute
contraindications listed in this policy exists.
* Mechanical or electric equipment that is used for manipulations and does not
meet the definition of “manual device” as specified in the “Description”
section of this policy.
* Coverage will be denied for lack of reasonable expectation that the
continuation of treatment would result in long-term improvement of the
patient’s condition; continued repetitive treatment without an achievable and
clearly defined goal is considered maintenance therapy and is not covered.
* The service is considered an extraspinal CMT.
* The service does not follow the guidelines of this policy.
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