471 Neb. Admin. Code, ch. 5, § 003

Current through September 17, 2024

Section 471-5-003 - SERVICE REQUIREMENTS

003.01GENERAL REQUIREMENTS.

003.01(A)MEDICAL NECESSITY. Medicaid incorporates the definition of medical necessity from 471 NAC 1 as is fully rewritten herein. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered.

003.01(B)SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

003.01(C)HEALTH CHECK SERVICES. See 471 NAC 33.

003.02COVERED SERVICES. Medicaid limits coverage of chiropractic services to:

(i) Certain spinal x-rays;

(ii) Manual manipulation of the spine;

(iii) Certain evaluation and management services;

(iv) Traction;

(v) Electrical stimulation;

(vi) Ultrasound; and

(vii) Certain therapeutic procedures, activities, and techniques designed and implemented to improve, develop, or maintain the function of the area treated.

003.02(A)CHIROPRACTIC TREATMENT. Covered services are only for the treatment of spinal subluxations for which treatment provides a direct therapeutic benefit, and is subject to the following limitations:

(i) For clients age 21 and older, chiropractic treatment is limited to those treatments deemed medically necessary;

(ii) For clients age 20 and younger, chiropractic treatment is limited to those treatments deemed medically necessary; and

(iii) No more than one treatment per client per day is covered.

003.02(B)SPINAL X-RAYS. Coverage of spinal x-rays is limited to one anteroposterior and one lateral view of the entire spine or one each of the following: thoracic, cervical, and lumbosacral for a client in a 12 month period. For spinal x-rays to be covered under Medicaid, at least one of the following criteria must be met:

(i) Recent acute or violent trauma where there may be a question concerning avulsion, fracture, or subluxation;

(ii) Chronic or long-standing ailments that have been treated by other practitioners without success and, if x-rays were already taken, they are not available;

(iii) When there is a pathology or malignancy previously diagnosed, precautionary x-rays are covered when medically necessary;

(iv) If there is any indication of existing pathology in the evaluation of the client, the treatment of which may cause additional discomfort;

(v) If the client has been under long-term treatment with no alleviation of symptoms; or

(vi) When specifically required by the Department's utilization review and for documentation of diagnosis and claims for services.

003.03NON-COVERED SERVICES. Except for those services previously specified, Medicaid does not cover any other diagnostic or therapeutic service or supply provided by a chiropractor.

471 Neb. Admin. Code, ch. 5, § 003

Amended effective 9/19/2020