Current through Vol. 42, No. 1, September 16, 2024
Chiropractic services are limited to manual spinal
manipulation. This includes the manipulation of the five (5) regions of the
spinal column for the treatment of back pain in a member with a primary
diagnosis of acute or chronic pain and is performed by a licensed
chiropractor.
(1)
Medical
necessity. All manual spinal manipulation services should be determined
to be medically necessary for the affected member. Documentation in the
member's plan of care should support the medical necessity of the need for
manual spinal manipulation services. The Oklahoma Health Care Authority (OHCA)
will serve as the final authority pertaining to all determinations of medical
necessity. Refer to Oklahoma Administrative Code (OAC)
317:30-3-1(f)
for policy on medical necessity.
(2)
Documentation/requirements.
All documentation submitted to request manual spinal manipulation services
should demonstrate, through adequate objective medical records, evidence
sufficient to justify the member's need for the service, in accordance with OAC
317:30-3-1(f)(2).
(A)
Evaluations. One (1) initial
evaluation and one (1) re-evaluation, for chiropractic manual spinal
manipulation, are allowed per calendar year and do not require a PA.
(B)
Prior authorization (PA).
Documentation, for a PA request, will include the following:
(i) The member is over twenty-one (21) years
of age;
(ii) Attestation stating
that manual spinal manipulation services are being used in place of opioid
treatment for pain or used to decrease the use of opioids;
(iii) Primary diagnosis of acute or chronic
spinal pain or neuromusculoskeletal disorder related to the spinal
column;
(iv) Plan of care that is
designed for the treatment of spinal pain;
(v) Signed informed consent for
care;
(vi) For full guidelines,
please refer to
www.okhca.org/mau.
(C)
Subsequent PA requests.
Requests for a subsequent PA will include the following:
(i) All documentation found at (2)(B)(i)
through (v) of this Section;
(ii)
Medical records that document that the treatments meet the functional needs of
the member;
(iii) Treatment goals
for acute pain/injury, chronic pain management, or chronic back pain;
(iv) Treatment evaluations that should
demonstrate improvement, including but not limited to, improved function,
decreased use of pain medications, increased activity level;
(v) Records showing persistent or recurrent
conditions;
(vi) For full
guidelines, please refer to
www.okhca.org/mau.
(3)
Frequency/coverage.
(A) SoonerCare covers up to twelve (12)
manual spinal manipulation visits per calendar year with an approved
PA.
(B) Manual spinal manipulation
for the treatment of acute or chronic back pain is the only chiropractic
service covered by SoonerCare.
(4)
Reimbursement. All
alternative treatments for pain management services, that are outlined in Part
82 of this Chapter, are reimbursed per the methodology established in the
Oklahoma Medicaid State Plan.
(5)
Discontinuation of services.
(A)
If the member's condition is not improving, or the member's condition is
regressing, services will not be considered medically necessary.
(B) The OHCA may withdraw authorization of
payment at any time if it is determined that the member and/or provider is not
in compliance with any of the requirements set forth in this Section.
(6)
Non-covered
services.
(A) Manual spinal
manipulation provided solely for maintenance.
(B) Chiropractor services that are not for
the alternative treatments of pain management listed in Part 82 of this
Chapter.
(C) Manual spinal
manipulation services that are provided in a setting other than the
chiropractor's office, including but not limited to, inpatient or outpatient
hospitals, nursing facilities, rest homes, or the member's home.
