Medicare Part B coverage for chiropractic services is highly specific and limited. The federal program only covers manual manipulation of the spine performed by a chiropractor to correct a vertebral subluxation. A subluxation is a segment of the spine where the alignment, movement, or function is altered. This strict limitation means Medicare recognizes two distinct categories of chiropractic visits: one that is covered, and one that is not.
Medically Necessary Active Treatment
The only type of chiropractic visit covered by Medicare is Medically Necessary Active Treatment. This phase of care must provide a reasonable expectation of recovery or significant improvement in the patient’s function. The treatment must also have a direct therapeutic relationship to the patient’s specific neuromusculoskeletal condition.
To qualify, the patient must have a spinal subluxation requiring corrective action, not just temporary pain relief. Subluxation is defined as a spinal motion segment where integrity or physiological function is altered, but joint contact remains intact. This condition must be documented through a recent X-ray or a detailed physical examination assessing asymmetry, range of motion, and tissue changes.
The treatment rendered must specifically be manual manipulation of the spine, utilizing the hands to correct the subluxation. This active care is necessary as long as the patient’s condition is improving or the treatment is arresting decline. The active treatment phase ends once the patient reaches maximum therapeutic benefit.
Supportive and Maintenance Care
The second type of visit, Supportive and Maintenance Care, is statutorily excluded from Medicare coverage. This care is defined as services provided after a patient has reached maximum clinical improvement. The purpose of maintenance care is to prevent disease, promote health, or maintain the patient’s current, non-improving condition.
When further clinical improvement is not reasonably expected from continuous ongoing care, the treatment is classified as maintenance therapy, which Medicare does not pay for. The goal of this care shifts from corrective action to supportive measures, such as preventing the deterioration of a chronic condition.
Medicare also does not cover several other services a chiropractor may perform or order, even during the active treatment phase. These statutorily excluded services include:
- Examinations and evaluations
- X-rays
- Therapeutic exercises
- Hot or cold packs
- Massage therapy
Patients must pay for these ancillary services entirely out-of-pocket, regardless of their condition.
Financial Responsibility and Notification
For the single covered service—manual manipulation during Medically Necessary Active Treatment—the patient is responsible for certain costs. The Medicare Part B deductible applies. After the deductible is met, the patient typically pays a 20 percent co-insurance of the Medicare-approved amount, and Medicare pays the remaining 80 percent.
When a chiropractor believes the patient’s care is transitioning from covered Active Treatment to non-covered Maintenance Care, they must issue an Advance Beneficiary Notice of Noncoverage (ABN). The ABN informs the beneficiary that Medicare is likely to deny payment for the service due to a lack of medical necessity.
This notice allows the patient to make an informed decision about receiving non-covered services and accepting financial responsibility. The ABN is mandatory only when the covered service (manual spinal manipulation) is expected to be denied for lack of medical necessity, such as when shifting to maintenance care. The ABN may also be used voluntarily to notify the patient of liability for services that are never covered, like X-rays or exams.