There are many insurance companies that provide excellent chiropractic coverage for participating members. However, there is a lot of confusion surrounding the type of coverage offered. Frequently insurance companies offer members a visit limit for chiropractic care and beyond that may state thast the member’s coverage is based on “Medical Necessity.”
What does it mean when insurance companies say coverage is based on Medical Necessity?
The coding book definition is “determination issued by the payer based on the payer’s review of a provider or insured’s request, and/or clinical documentation for specific service or supply.”
The insurance definition is “services are excluded if, based on medical evidence, treatment or continued treatment could not be expected to resolve or improve the condition, or that clinical evidence indicates that a plateau has been reached in terms of improvement from such services.”
What does that mean for you in plain English?
If an insurance plan states “coverage is based on Medical Necessity” for chiropractic care, care is only billable during a set treatment plan for treatment of a condition or pain. “Routine,” “preventative,” or “wellness” visits unfortunately do not fall within this restriction. It is unfortunate maintenance visits are frequently not covered by insurance companies because, similar to eating healthy or exercising frequently, you are taking care of your health for your current & future self. Pain is often the last thing to come and the first thing to go! However, insurance companies frequently perform audits for care they have paid for in “error” – which can be detrimental for patients. The “routine” is where we are seeing the most issues. Their feeling is that if you’re in the type of pain that improves with Chiropractic care then regularly scheduled monthly visits are infrequent and thus must be wellness.
If your insurance company tells us that they only cover “medically necessary care”, we highly recommend you call them directly and discuss how often you’re coming in and why. The contract is between you and your insurance company (not between AHC and them), so they may be more apt to ok it for you. If that’s the case, take down a name and reference number in case they deny in the future so that you’ll have the information.
We try to be as transparent as possible about insurance benefits and cost of care because we know this effects all individuals. If you are ever confused about your chiropractic coverage through insurance, please don’t hesitate to let me know!