Medicare Maintenance Care Notice

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Maintenance Care Notice

Necessity for treatment by Medicare

Medicare does not cover Maintenance Therapy for your spinal joint problems.

The official Medicare guidelines that define your benefits are reprinted below.

Medicare Carriers Manual, Part 3, Chapter 2 – Section 2251.3 – Necessity for Treatment

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 a reasonable expectation of recovery or improvement or function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam.

Most spinal joint problems fall into the following categories:

Acute Subluxation (misalignment) – A patient’s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of Chiropractic manipulation is expected to be an improvement in, or arrest of, progression of the patient’s condition.

Chronic Subluxation (misalignment) – A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

Maintenance Therapy – Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

In summary, when you have an Acute condition (e.g. injury or re-injury), or a Chronic condition that needs rehabilitation, it is covered by Medicare. However, Medicare does not cover Maintenance Therapy for keeping you well after you are stabilized. The decision-making process in our office for placing you in one of these three categories above is based on:

1) Outcomes assessment scores,

2) Patient history and physical examination, and

3) “Global Impression of Change” by the patient.

If you have questions or disagree with your clinical category, please discuss it with us.

Thank you,

Dr. Sharon Levin and  Dr. Nels Chellen