Asset Publisher


print Print

Spinal Manipulation of Non-Neuromusculoskeletal Conditions

Policy Number: MP-240

Latest Review Date: June 2024

Category: Therapy                                                                 


Spinal manipulation of non-neuromusculoskeletal conditions is considered not medically necessary.

Non-neuromusculoskeletal conditions may include, but are not limited to:

  • Otitis media
  • Asthma
  • Constipation
  • Colic
  • Gastric reflux
  • Insomnia
  • Hypertension
  • Obesity
  • Allergies
  • Epilepsy
  • Autism
  • Attention Deficit/Hyperactivity Disorder


Manipulation is a manual procedure that involves a directed thrust to move a joint past its physiological range of motion, without exceeding the anatomical limit.

Manual manipulation of the spine can be an effective means of treating pain and nerve interference due to subluxation of the spine.  Spinal subluxation is defined as an incomplete dislocation, misalignment, or abnormal spacing of the vertebrae anatomically.  This results in inflammation of the joint and capsule leading to pain, swelling, muscle spasm nerve irritation, cartilage damage and loss of range of motion.  Vascular, sensory and motor changes may also occur.


Very few randomized clinical trials of manipulation as a treatment of non-spinal conditions exist.  Most studies involving the long-term safety and effectiveness of spinal manipulation have been done on adult populations.  The long-term safety and effectiveness of the use of spinal manipulation in the treatment of non-neuromusculoskeletal conditions have not been proven through long-term, randomized controlled clinical trials.

Although some review articles report that spinal manipulation improves breathing in asthma patients, Balon et al reported in their randomized, controlled trial of chiropractic spinal manipulation for 91 children with mild to moderate asthma that the addition of spinal manipulation to usual medical care provided no benefit.


Spinal manipulation, Osteopathic manipulative treatment (OMT), Chiropractic manipulative treatment (CMT).


Not applicable


Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply. Refer to member’s benefit plan.


CPT Codes:


Manual therapy techniques (e.g. Mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes


Osteopathic manipulative treatment (OMT); one to two body regions involved


                        ;three to four body regions involved


                        ;five to six body regions involved


                        ;seven to eight body regions involved


                        ;nine to ten body regions involved


Chiropractic manipulative treatment (CMT); spinal, one to two regions


                        ;spinal, three to four regions


                        ;spinal, five regions


                        ;extraspinal, one or more regions

 Note: Evaluation and management or consultation codes should not be used to bill for spinal manipulation.


  1. Alcantara J, Alcantara JD, Alcantara J. The chiropractic care of patients with asthma: A systematic review of the literature to inform clinical practice. Clinical Chiropractic 2012; 15(1):23-30
  2. Balon J, Aker PD, et al.  A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. N Eng J Med 1998;339(15):1013-20.
  3. Carnes D, Plunkett A, Ellwood J, et al. Manual therapy for unsettled, distressed and excessively crying infants: A systematic review and meta-analyses. BMJ Open 2018;8:e019040.
  4. Clar C, Tsertsvadze A, Court R, et al. Clinical effectiveness of manual therapy for the management of musculoskeletal and nonmusculoskeletal conditions: Systematic review and update of UK evidence report. Chiropr Man Therap. 2014 Mar 28;22(1):12.
  5. Dobson D, Lucassen PL, Miller JJ, et al. Manipulative therapies for infantile colic. Cochrane Database Syst Rev. 2012 Dec 12;12:CD004796.
  6. Driehuis, F., Hoogeboom, T. J., Nijhuis-van der Sanden, et al. (2019). Spinal manual therapy in infants, children and adolescents: A systematic review and meta-analysis on treatment indication, technique and outcomes. PloS one, 14(6), e0218940.
  7. Ernst E. Chiropractic treatment for gastrointestinal problems: A systematic review of clinical trials. Can J Gastroenterol 2011; 25:39–40.
  8. Fitzmaurice L. Integrative medicine and pediatric emergency medicine: Can they be complementary? Clin Pediat Emerg Med 2004;5(4).
  9. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
  10. Jones, L. M., Regan, C., Wolf, K., Bryant, J., Rakowsky, A., Pe, M., & Snyder, D. A. (2021). Effect of osteopathic manipulative treatment on pulmonary function testing in children with asthma. Journal of Osteopathic Medicine, 121(6), 589–596.
  11. Karpouzis F, Bonello R, Pollard H. Review of chiropractic care for paediatric and adolescent attention-deficit/hyperactivity disorder: A systematic review. Chiropr Osteopat. 2010 Jun 2;18:13.
  12. Kingston J, Raggio C, Spencer K, et al. A review of the literature on chiropractic and insomnia. J Chiropractic Med 2010; 9:121– 126.
  13. Leighton JM. Does manual therapy such as chiropractic offer an effective treatment modality for chronic otitis media? Clinical Chiropractic 12(4):144-148.
  14. Mangum K, Partna L, Vavrek D. Spinal manipulation for the treatment of hypertension: a systematic qualitative literature review. J Manipulative Physiol Ther. 2012; 35:235–243.
  15. Müller A, Franke H, Resch KL, et al. Effectiveness of osteopathic manipulative therapy for managing symptoms of irritable bowel syndrome: A systematic review. J Am Osteopath Assoc. 2014; 114:470–479.
  16. Pohlman KA, Holton-Brown MS. Otitis media and spinal manipulative therapy: a literature review. J Chiropr Med. 2012 Sep;11(3):160-9.
  17. Posadzki P, Lee MS, Ernst E. Osteopathic manipulative treatment for pediatric conditions a systematic review. Pediatrics 2013; 132:140–152.
  18. Rosner AL. Infant and child chiropractic care: An assessment of research. Foundation for Chiropractic Education and Research 2003.


Medical Policy Group, July 2005 (1)

Medical Policy Administration Committee, July 2005

Available for comment August 6-September 19, 2005

Medical Policy Group, September 2012: Effective September 14, 2012 this policy is no longer scheduled for regular literature reviews and updates.

Medical Policy Group, October 2013 (1): Removed ICD-9 Diagnosis/Procedure codes; no change to policy statement.

Medical Policy Group, July 2019 (7): Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, June 2021 (7): Reviewed by consensus. Updated References. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, June 2022 (7): Reviewed by consensus. Updated References. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, June 2023 (7): Reviewed by consensus. Update to Benefit Application and References. No change to Policy Statement.

Medical Policy Group, June 2024 (7): Reviewed by consensus. References added. No change to Policy Statement.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

  1.  The technology must have final approval from the appropriate government regulatory bodies;
  2.  The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
  3.  The technology must improve the net health outcome;
  4.  The technology must be as beneficial as any established alternatives;
  5.  The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

  1.  In accordance with generally accepted standards of medical practice; and
  2.  Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
  3.  Not primarily for the convenience of the patient, physician or other health care provider; and
  4.  Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.