Chiropractor's Opinion Concerning Subluxation Takes
Precedence Over Medical Radiologist's, HCFA Confirms

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

In a significant step toward parity for the chiropractic profession under the Medicare program, the Health Care Financing Administration (HCFA) has clarified that a doctor of chiropractic's findings of a subluxation in a Medicare patient takes precedence over the opinion of a medical radiologist. In addition, at the request of the American Chiropractic Association (ACA), HCFA has clarified that chiropractic principles and definitions of a subluxation are to be used to determine Medicare coverage, and an existing MRI may be used to demonstrate the existence of a subluxation in a Medicare patient.

HCFA issued the clarifications after ACA expressed concerns that Medicare claims were being unfairly denied in various regions across the country because radiologists had been contradicting chiropractor's diagnoses.

"I understand this issue of interpretation of the x-ray has been raised when the radiologist, assuming responsibility for ordering the x-ray to demonstrate subluxation and, thus, satisfy the requirements of 1861(r)(5) of the Social Security Act, fails to find the subluxation," wrote Grant Bagley, M.D., a senior HCFA medical officer, in a May 12 letter to ACA executive vice president Garrett F. Cuneo. "It is our understanding that based on Section 2250 of the Medicare Carrier's Manual (MCM), that the chiropractor has the final determination of the subluxation. Section 2250 states that judgements about the reasonableness of chiropractic treatment must be based on chiropractic principles. Further, the MCM recommends that chiropractic consultation be sought in review of chiropractic claims."

In addition, HCFA has affirmed that an existing MRI may be used in place of an x-ray or CT scan to demonstrate the subluxation, a clarification that will prevent Medicare patients from being subjected to unnecessary x-ray exposure. This does not mean, however, that a new MRI or CT scan should be taken specifically for the purpose of showing the subluxation, HCFA has advised. Doctors should also note that the x-ray, MRI or CT scan must be taken within the time frame specified in the MCM- 12 months before or three months following the initiation of chiropractic treatment."

"HCFA's latest clarifications represent yet another important step in ACA's efforts to ensure fairness for doctors of chiropractic under the Medicare program,"

Reprinted from the June ACA Today by permission

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