Covered Services

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• Acupuncture Services
• Chiropractic Services
• Evaluation and Management Services
• Radiology

Helpful Links

• Chiropractic Services chapter of the Minnesota Health Care Programs (MHCP) Provider Manual
• Acupuncture Services chapter of the MHCP Provider Manual

Acupuncture Services

Definition

“Acupuncture practice” means a comprehensive system of health care using Oriental medical theory and its unique methods of diagnosis and treatment. Treatment techniques include the insertion of acupuncture needles through the skin and use of other biophysical methods of acupuncture point stimulation, including the use of heat, Oriental massage techniques, electrical stimulation, herbal supplemental therapies, dietary guidelines, breathing techniques, and exercise based on Oriental medical principles

Eligible Providers

The following licensed practitioners may provide acupuncture:

1. Acupuncturists
2. Chiropractors who have complied with the Minnesota Board of Chiropractic Examiners’ acupuncture registration requirements
3. Osteopaths
4. Physicians

Eligible Members

PrimeWest Health members under age 21 are eligible for chiropractic services. Refer to Member Eligibility and Benefits for coverage determination information.

Covered Services

Acupuncture is covered for chronic pain. Chronic pain is defined as pain with duration of at least six consecutive months. In addition to documentation of the cause/origin of the chronic pain, a comprehensive history and physical evaluation of the member by a qualified medical provider is required. This requirement must be met prior to the start of acupuncture treatment and must be documented in the member’s record. Documentation must be provided to PrimeWest Health if, upon monitoring the utilization trend, PrimeWest Health determines an audit is necessary to determine medical need for the services provided.

An acupuncturist cannot bill for evaluation and management codes for evaluation of the member.

Acupuncture is covered for the following conditions:

• Acute pain
• Chronic pain
• Depression
• Anxiety
• Schizophrenia
• Post-Traumatic Stress Disorder (PTSD)
• Insomnia
• Smoking cessation
• Restless legs syndrome
• Menstrual disorders
• Xerostomia (dry mouth) associated with the following:
  • Sjogren’s syndrome
  • Radiation therapy
• Nausea and vomiting associated with the following:
  • Post-operative procedures
  • Pregnancy
  • Cancer care

PrimeWest Health does not cover maintenance treatment when symptoms are not regressing or showing improvement. Acupuncture treatment is not considered medically necessary if the member does not show improvement in symptoms.

Acupuncture services are billable by chiropractors and acupuncturists when provided according to the requirements defined in this section.

Acupuncture for pain and other specific conditions must be performed by a doctor of medicine (MD), licensed acupuncturist, osteopath, or chiropractor who has complied with the Minnesota Board of Chiropractic Examiners’ acupuncture requirements.

Before the start of acupuncture treatment, the acupuncture provider must document a brief history of the member’s presenting condition. The medical record must also include the acupuncture provider’s documentation of a limited exam of the condition being treated or the affected body area.

PrimeWest Health requires prior authorization for acupuncture services after a member has received 20 units within a calendar year. If requesting additional units, documentation must include the following:

1. The diagnosis for the cause or origin of the symptom being treated
2. Evidence that the member is responding favorably to the acupuncture treatment and that further improvement is expected with additional treatment
3. The acupuncture technique being requested
4. A comprehensive history and physical evaluation of the member
5. Plan of care for the acupuncture treatment
6. Other treatments the member is receiving for the diagnosis, regardless of where or by whom they are being treated. Examples of other treatment may include opioids, physical therapy, and medical cannabis.
7. When applicable, provide documentation that favorable outcomes from acupuncture treatments have reduced the member’s need for opioids or led to improved utilization of other treatment modalities.

Use the Physician Extender modifier for non-physician services. 

Chiropractic Services

Extraspinal manipulative treatment (98943) and physiotherapeutic codes are not covered codes.

Documentation Requirements

Initial Chiropractic Visit

Document the following for the initial chiropractic visit:

1. Date of initial treatment
2. History; include the following:
   1. Symptoms causing member to seek treatment
   2. Family history, if relevant
   3. Past health history (general health, prior illness, injuries or hospitalizations, medications, surgical history)
   4. Mechanism of trauma
   5. Quality and character of symptoms or problem
   6. Onset, duration intensity, frequency, location, and radiation of symptoms
   7. Aggravating or relieving factor
   8. Prior interventions, treatment, medications, secondary complaints
3. Description of presenting condition or complaints, including the following:
   1. Mechanism of trauma
   2. Quality and character of symptoms or problem
   3. Onset, duration intensity, frequency, location, and radiation of symptom
   4. Aggravating or relieving factors
   5. Prior interventions, treatment, medications, secondary complaints
   6. Symptoms causing member to seek treatment
4. Evaluation of musculoskeletal or nervous system through physical examination
5. Diagnosis: subluxation must be the primary diagnosis
6. Treatment plan which includes the following:
   1. Recommended level of care
   2. Specific treatment goals
   3. Objective measures to evaluate effectiveness of treatment

Subsequent Visits

Documentation required for subsequent visits include:

1. History
   1. Review of chief complaint
   2. Changes since last visit
   3. System review, if relevant
2. Physical exam
   1. Exam of area of spine involved in diagnosis
   2. Assessment of change in member's condition since last visit
   3. Evaluation of treatment effectiveness
   4. Documentation of treatment provided on day of visit

Authorization Requirements

Authorization is required for any combination of Current Procedural Terminology (CPT) codes 98940, 98941, and 98942 in excess of six per month or 24 per calendar year.  Submit authorization for only the number of units in excess of the benefit coverage allowed. If a member needs eight treatments in a month, your request must ask for two additional treatments, not eight.

Criteria

The diagnosis of subluxation may be demonstrated using X-ray or physical examination. If X-rays (or radiologic report) are used, the X-ray (or radiologic report) must be no older than 12 months prior to the start of treatment.

Documenting Subluxation by Physical Examination

Evaluation of musculoskeletal/nervous system to identify the following:

1. Pain/tenderness evaluated in terms of location, quality, and intensity
2. Asymmetry/misalignment identified on a sectional or segmental level
3. Range of motion abnormality (changes in active, passive, and accessory joint)
4. Changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament (change in tone)

Two of the above criteria are required to demonstrate subluxation based on physical examination; one of which must be:

1. Asymmetry/misalignment
2. Range of motion abnormality

This documentation must be provided to PrimeWest Health if, upon monitoring the utilization trend, we find the need to do an audit to determine medical need of the services provided.

Evaluation and Management (E/M) Services

1. Evaluation and Management (E/M) services for new and established patients, not to exceed one per calendar year. E/M services can be billed on the same date as the manipulation.
2. Manual manipulation of the spine for treatment of subluxation (incomplete or partial dislocation) determined to be medically necessary by generally accepted chiropractic standards of care.

Radiology

X-Ray Codes

Payment Limitations

Payment for X-rays is limited to radiological examinations of the full spine, including the following:

1. Cervical
2. Thoracic
3. Lumbar
4. Lumbosacral
5. Pelvis
6. Sacroiliac joints

Radiology services for PrimeWest Senior Health Complete and Prime Health Complete members are covered by the Medicaid wraparound benefit.

Providers must submit the most applicable diagnosis codes (International Classification of Diseases, 10^th Revision, Clinical Modification [ICD-10-CM]) when billing for subluxation on claims.

X-rays that are needed to support a diagnosis of subluxation are covered.

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Updated_01/14/2026