Chiropractic Insurance Claim Denied: How to Appeal Spinal Manipulation Coverage

Chiropractic Insurance Claim Denied: How to Appeal Spinal Manipulation Coverage

Chiropractic care — including spinal manipulation, manual therapy, and related services — is covered by most major US health insurance plans, yet claim denials for chiropractic treatment are extremely common. The most frequent reason is that insurers argue treatment is no longer "medically necessary" once a patient's condition has "plateaued" — even when the patient and their chiropractor know that ongoing maintenance treatment is clinically important.

This guide explains the most common reasons for chiropractic claim denials and how to appeal them effectively.

Why Chiropractic Claims Are Denied

"No longer medically necessary" / Plateau denial: This is the most common chiropractic denial. After a certain number of visits, your insurer's utilisation management team concludes that you have reached "maximum therapeutic benefit" and that additional treatment is maintenance (not medically necessary active treatment). Further claims are denied.

Visit limit exceeded: Many insurance plans cap chiropractic visits at a specific number per year (e.g., 12, 20, or 30 visits). Once the cap is reached, further claims are denied. These caps may violate the Mental Health Parity Act in certain circumstances.

Prior authorisation not obtained: Some plans require prior authorisation after an initial number of visits. If authorisation wasn't obtained, claims for additional visits are denied.

Service not covered: Some insurance plans (particularly HMO plans with limited extras) may not cover chiropractic treatment at all, or may cover it only at in-network chiropractors.

Maintenance care exclusion: Plans often distinguish between "active treatment" (medically necessary improvement expected) and "maintenance care" (treatment to maintain a level of function). Maintenance care is frequently excluded.

Condition classification issues: Chiropractic claims for chronic conditions (like chronic low back pain) may be classified as maintenance rather than active treatment even when the patient is experiencing acute flare-ups or functional deterioration.

The Plateau / Medical Necessity Denial: How to Fight Back

The key to fighting a "plateau" denial is demonstrating that your treatment is active treatment producing measurable clinical improvement — not merely maintenance.

Your chiropractor should document:

• Specific functional improvements from the last course of treatment (measurable — range of motion, pain scale, functional activity levels)
• Current functional limitations that require active treatment
• Treatment plan with specific, measurable goals for the upcoming treatment period
• Why ongoing treatment is expected to produce further improvement (not merely maintain current status)

If you have a chronic condition that episodically worsens (e.g., recurrent herniated disc, scoliosis, degenerative disc disease), your chiropractor should frame the current visit series as treatment for an acute exacerbation, not ongoing maintenance.

Mental Health Parity and Chiropractic Visit Limits

MHPAEA (Mental Health Parity and Addiction Equity Act) prohibits insurers from applying more restrictive limits to mental health and substance use disorder benefits than to comparable medical/surgical benefits. While chiropractic is generally not classified as a mental health benefit, some courts and regulators have considered parity arguments for physical therapy and chiropractic in the context of:

• Unlimited physical therapy for certain medical conditions vs. capped chiropractic visits
• The argument that chronic pain management through chiropractic is a medical treatment that should not have caps that don't exist for other chronic pain treatments

More directly applicable: most states prohibit insurance plans from imposing annual visit limits on chiropractic that differ from visit limits on other comparable outpatient treatments. State chiropractic access laws exist in many states.

Step-by-Step: Appealing a Chiropractic Claim Denial

Step 1: Identify the Denial Reason

Review your insurer's denial:

• Is this a "no longer medically necessary" / plateau denial?
• Is this a visit limit cap?
• Is this a prior authorisation issue?
• Is this a maintenance care classification?

Step 2: Get Your Chiropractor's Comprehensive Documentation

Your chiropractor's documentation is the foundation of your appeal:

Progress notes showing active treatment need:

• Objective findings at each visit (range of motion measurements, neurological findings, orthopaedic test results)
• Measurable improvement documented over the course of treatment
• Current deficits and functional limitations
• Patient-reported pain and function scores (using validated tools like the Oswestry Disability Index or Neck Disability Index)

Treatment plan for the continued/appealed period:

• Specific treatment goals
• Why improvement is expected (not just maintenance)
• Frequency and duration of proposed treatment

Doctor's letter supporting ongoing treatment:

• Your chiropractor's formal appeal letter explaining why continued treatment is medically necessary active treatment

Physician or specialist support:

• Letter from your primary care physician, orthopaedist, or neurologist supporting chiropractic treatment for your condition

Step 3: Address the Insurer's Specific Criteria

Request your insurer's medical necessity criteria for chiropractic treatment and address each criterion directly in your appeal. Common criteria that insurers use to deny chiropractic claims:

• "Maximum medical improvement (MMI) reached"
• "Objective improvement not documented"
• "Treatment goals not defined"

For each criterion your insurer cites, your chiropractor's documentation should demonstrate the opposite.

Step 4: Submit Your Appeal

Your appeal letter should:

• Directly quote the insurer's denial criteria
• Provide point-by-point evidence that you meet the criteria for continued treatment
• Reference clinical guidelines (e.g., American College of Physicians (ACP) guidelines on low back pain, which now recommend non-pharmacological approaches like chiropractic as first-line treatment)
• Include all your chiropractor's documentation

Step 5: Request External Review

After exhausting internal appeals, request external review. External reviewers apply national clinical standards. For chiropractic denials, ACP guidelines recommending spinal manipulation for back pain are powerful supporting evidence.

Step 6: File a State Insurance Complaint

If your insurer is applying visit caps that appear inconsistent with your state's laws, file a complaint with your state's Department of Insurance.

Visit Limits: Know Your State's Rules

Many states have laws limiting how restrictive insurers can be in applying visit caps to chiropractic:

• Some states prohibit annual visit caps on chiropractic if comparable physical therapy has no cap
• Some states require that chiropractic visit limits be the same as physical therapy visit limits
• Check your state's insurance laws or consult your state's Department of Insurance

Medicare and Chiropractic

Medicare (Parts A and B) covers chiropractic (spinal manipulation) for the correction of subluxations that are demonstrated to be causing specific conditions (e.g., acute or chronic low back pain with documented subluxation). Medicare does NOT cover:

• Maintenance chiropractic care
• X-rays taken by the chiropractor
• Massage, ultrasound, or other physical modalities

If Medicare denies chiropractic, you have standard Medicare appeal rights. Key tip: ensure your chiropractor documents active subluxation at each visit as the Medicare billing requirements are strict.

Conclusion

Chiropractic claim denials are frequently based on "plateau" determinations that don't hold up to proper clinical scrutiny when the chiropractor's documentation clearly shows ongoing active treatment producing measurable improvement. The key is thorough, objective clinical documentation and an appeal that directly addresses your insurer's criteria. Use ClaimBack at claimback.app to generate a professional appeal letter for your chiropractic insurance denial.

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• Spinal Surgery Insurance Denied: How to Appeal
• Occupational Therapy Insurance Denied: How to Appeal
• How to Negotiate with Your Insurance Company
• Insurance Bad Faith: Your Rights When an Insurer Wrongfully Denies