441—78.8 (249A) Chiropractors. Payment will be made for the same chiropractic procedures payable under Title XVIII of the Social Security Act (Medicare).
	 78.8(1) Covered services. Chiropractic manipulative therapy (CMT) eligible for reimbursement is specifically limited by Medicaid to the manual manipulation (i.e., by use of the hands) of the spine for the purpose of correcting a subluxation demonstrated by X-ray. Subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebrae.
	 78.8(2) Indications and limitations of coverage.
	  a.   	 The subluxation must have resulted in a neuromusculoskeletal condition set forth in the table below for which CMT is appropriate treatment. The symptoms must be directly related to the subluxation that has been diagnosed. The mere statement or diagnosis of “pain” is not sufficient to support the medical necessity of CMT. CMT must have a direct therapeutic relationship to the patient’s condition. No other diagnostic or therapeutic service furnished by a chiropractor is covered under the Medicaid program.

ICD-9	CATEGORY I	ICD-9	CATEGORY II	ICD-9	CATEGORY III	
307.81	Tension headache	353.0	Brachial plexus lesions	721.7	Traumatic spondylopathy	
721.0	Cervical spondylosis
without myelopathy	353.1	Lumbosacral plexus lesions	722.0	Displacement of cervical intervertebral disc without myelopathy	
721.2	Thoracic spondylosis
without myelopathy	353.2	Cervical root lesions, NEC	722.10	Displacement of lumbar
intervertebral disc without myelopathy	
721.3	Lumbosacral spondylosis without myelopathy	353.3	Thoracic root lesions, NEC	722.11	Displacement of thoracic intervertebral disc without myelopathy	
723.1	Cervicalgia	353.4	Lumbosacral root lesions, NEC	722.4	Degeneration of cervical intervertebral disc	
724.1	Pain in thoracic spine	353.8	Other nerve root and
plexus disorders	722.51	Degeneration of thoracic
or thoracolumbar intervertebral disc	
724.2	Lumbago	719.48	Pain in joint (other specified sites, must specify site)	722.52	Degeneration of lumbar
or lumbosacral intervertebral disc	
724.5	Backache, unspecified	720.1	Spinal enthesopathy	722.81	Post laminectomy syndrome, cervical region	
784.0	Headache	722.91	Calcification of intervertebral cartilage or disc, cervical region	722.82	Post laminectomy syndrome, thoracic region	
 	 	722.92	Calcification of intervertebral cartilage or disc, thoracic region	722.83	Post laminectomy syndrome, lumbar region	
 	 	722.93	Calcification of intervertebral cartilage or disc, lumbar region	724.3	Sciatica	
 	 	723.0	Spinal stenosis in cervical region	 	 	
 	 	723.2	Cervicocranial syndrome	 	 	
 	 	723.3	Cervicobrachial syndrome	 	 	
 	 	723.4	Brachial neuritis or radiculitis, NOC	 	 	
 	 	723.5	Torticollis, unspecified	 	 	
 	 	724.01	Spinal stenosis, thoracic region	 	 	
 	 	724.02	Spinal stenosis, lumbar region	 	 	
 	 	724.4	Thoracic or lumbosacral neuritis or radiculitis	 	 	
 	 	724.6	Disorders of sacrum, ankylosis	 	 	
 	 	724.79	Disorders of coccyx, coccygodynia	 	 	
 	 	724.8	Other symptoms referable to back, facet syndrome	 	 	
 	 	729.1	Myalgia and myositis, unspecified	 	 	
 	 	729.4	Fascitis, unspecified	 	 	
 	 	738.40	Acquired spondylolisthesis	 	 	
 	 	756.12	Spondylolisthesis	 	 	

ICD-9	CATEGORY I	ICD-9	CATEGORY II	ICD-9	CATEGORY III	
 	 	846.0	Sprains and strains of sacroiliac region, lumbosacral (joint; ligament)	 	 	
 	 	846.1	Sprains and strains of sacroiliac region, sacroiliac ligament	 	 	
 	 	846.2	Sprains and strains of sacroiliac region, sacrospinatus (ligament)	 	 	
 	 	846.3	Sprains and strains of sacroiliac region, sacrotuberous (ligament)	 	 	
 	 	846.8	Sprains and strains of sacroiliac region, other specified sites of sacroiliac region	 	 	
 	 	847.0	Sprains and strains, neck	 	 	
 	 	847.1	Sprains and strains, thoracic	 	 	
 	 	847.2	Sprains and strains, lumbar	 	 	
 	 	847.3	Sprains and strains, sacrum	 	 	
 	 	847.4	Sprains and strains, coccyx	 	 	
	  b.   	 The neuromusculoskeletal conditions listed in the table in paragraph “a” generally require short-, moderate-, or long-term CMT. A diagnosis or combination of diagnoses within Category I generally requires short-term CMT of 12 per 12-month period. A diagnosis or combination of diagnoses within Category II generally requires moderate-term CMT of 18 per 12-month period. A diagnosis or combination of diagnoses within Category III generally requires long-term CMT of 24 per 12-month period. For diagnostic combinations between categories, 28 CMTs are generally required per 12-month period. If the CMT utilization guidelines are exceeded, documentation supporting the medical necessity of additional CMT must be submitted with the Medicaid claim form or the claim will be denied for failure to provide information.
	  c.   	 CMT is not a covered benefit when:
	 (1) 	 The maximum therapeutic benefit has been achieved for a given condition.
	 (2) 	 There is not a reasonable expectation that the continuation of CMT would result in improvement of the patient’s condition.
	 (3) 	 The CMT seeks to prevent disease, promote health and prolong and enhance the quality of life.
	 78.8(3) Documenting X-ray. An X-ray must document the primary regions of subluxation being treated by CMT.
	  a.   	 The documenting X-ray must be taken at a time reasonably proximate to the initiation of CMT. An X-ray is considered to be reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of CMT. X-rays need not be repeated unless there is a new condition and no payment shall be made for subsequent X-rays, absent a new condition, consistent with paragraph “c” of this subrule. No X-ray is required for pregnant women and for children aged 18 and under.
	  b.   	 The X-ray films shall be labeled with the patient’s name and date the X-rays were taken and shall be marked right or left. The X-ray shall be made available to the department or its duly authorized representative when requested. A written and dated X-ray report, including interpretation and diagnosis, shall be present in the patient’s clinical record.
	  c.   	 Chiropractors shall be reimbursed for documenting X-rays at the physician fee schedule rate. Payable X-rays shall be limited to those Current Procedural Terminology (CPT) procedure codes that are appropriate to determine the presence of a subluxation of the spine. Criteria used to determine payable X-ray CPT codes may include, but are not limited to, the X-ray CPT codes for which major commercial payors reimburse chiropractors. The Iowa Medicaid enterprise shall publish in the Chiropractic Services Provider Manual the current list of payable X-ray CPT codes. Consistent with CPT, chiropractors may bill the professional, technical, or professional and technical components for X-rays, as appropriate. Payment for documenting X-rays shall be further limited to one per condition, consistent with the provisions of paragraph “a” of this subrule. A claim for a documenting X-ray related to the onset of a new condition is only payable if the X-ray is reasonably proximate to the initiation of CMT for the new condition, as defined in paragraph “a” of this subrule. A chiropractor is also authorized to order a documenting X-ray whether or not the chiropractor owns or possesses X-ray equipment in the chiropractor’s office. Any X-rays so ordered shall be payable to the X-ray provider, consistent with the provisions in this paragraph.
This rule is intended to implement Iowa Code section 249A.4.