Who Defines Medical Necessity?
All third party-payers, including Medicare, get to decide what type of chiropractic care they will actually pay for and what the definition of medical necessity is for their insured. Below you will see a couple of examples of medical necessity definitions for chiropractic care. Medicare is very straight-forward in its description of medical necessity in a chiropractic office, other carriers are not as helpful.
Medicare’s Medical Necessity Definition:
“The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.”
Aetna Shares About Medical Necessity:
Some plans have limitations or exclusions applicable to chiropractic care. Please check benefit plan descriptions for details.
My Chiropractic Claims Just Got Denied for Medical Necessity. Now What?
Make sure the care you rendered met the stated medical necessity definition of the third-party payer. Also, verify your chiropractic documentation contains all the required details to prove their definition of medical necessity was met. Begin the appeals process to get your chiropractic claim properly adjudicated.
...Kathy is the real deal!!! She's so committed to helping us through the labyrinth!!!!! I love her very clear and precise communication style. She keeps you on your toes without making you feel bad. I feel like she understands both sides of the game: what we are going through in our offices and what's happening in the payer's playing field. This is a very valuable coach!!!!