Okla. Admin. Code § 317:30-5-727

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-727 - Manual spinal manipulation

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.

Okla. Admin. Code § 317:30-5-727

Adopted by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/12/2022