#	Category	Title	Description
71	Coding	Reporting Spinal Chiropractic Manipulative Treatment (CMT) Levels	This policy describes the criteria approved by Optum® for the reporting of chiropractic manipulative treatment (CMT) procedural code levels. This document is intended to inform healthcare provider decision-making concerning the reporting of spinal CMT levels. When applicable, this policy serves as the clinical criteria for utilization review (UR) determinations.
73	Imaging/Testing	General Guidelines for the Use of Plain-Film Spinal Radiography	This policy will define the indications and contraindications for utilization of AP and Lateral Plain View Radiographs. The policy is designed for patient safety and to assist health care providers and support clinicians in consistently evaluating for clinical need. The final determination of clinical need depends upon correlation of the patient`s presenting clinical picture. The information provided must have a meaningful impact on patient management.
81	Determinations	Extraspinal Manual Therapy Interventions	This policy serves as the criterion for peer-reviewer decisions concerning extraspinal manipulation and/or mobilization therapy for the treatment of neuromusculoskeletal disorders. This policy also serves as a resource for peer-to-peer interactions in describing the position of Optum® on the application of extraspinal manipulation/mobilization procedures for neuromusculoskeletal disorders. [Plain Language Summary]
84	Determinations	Determination of Maximum Therapeutic Benefit	This policy has been developed to describe the current evidence-basis for the determination of maximum therapeutic benefit (MTB) in the management of neuromusculoskeletal disorders. Additionally, this policy acknowledges individual health care provider accountabilities in assessing for MTB and appropriate clinical decision-making once MTB has been reached. [Plain Language Summary]
94	Determinations	Determination of Safety to Deliver Thrust Joint Manipulation to a Specific Region	This policy describes the criteria used to ensure that utilization review determinations consider the safety of proposed thrust joint manipulation to a region.
95	Determinations	Scoliosis: Conservative Interventions	This policy has been developed as the clinical criterion that describes the position of Optum® regarding the efficacy, effectiveness, risks, and burdens associated with the use of conservative interventions (manual therapy, exercise, bracing, whole body vibration and non-operative traction) for the treatment of idiopathic scoliosis. [Plain Language Summary]
302	Determinations	Manual Therapy	This policy has been developed to describe the criteria that Optum® uses to conduct utilization review for services described as manual therapy including joint manipulation.
337	Compliance	Utilization Management Overview	The policy was developed to describe the required process of utilization review used by Optum® and essential for compliance with applicable state, federal and agency requirements or mandates. The process detail is incorporated into the Optum® Utilization Management (UM) Program. Individual Plan requirements supplement the UM Program.
342	Determinations	Manual Therapy Interventions for Non-Musculoskeletal Disorders	This policy serves as the criterion for utilization review decisions concerning manual therapy interventions including spinal and extraspinal manipulation/mobilization therapy for the treatment of non-musculoskeletal disorders. [Plain Language Summary]
348	Determinations	Application of Clinical Algorithms	To summarize the application of clinical algorithms.
350	Determinations	Experimental and Investigational Technologies	To describe the guidelines for processing submitted cases, where the intervention proposed is determined to be experimental and/or investigational.
359	Imaging/Testing	Electrodiagnostic Testing	This policy has been developed as the clinical criterion that describes the position of Optum® regarding the appropriate application of electrodiagnostic (electrophysiological) testing for the evaluation of neuromuscular disorders.
362	Determinations	Established Patient Re-evaluation	This policy has been developed to describe the criteria that OptumHealth Care Solutions, LLC (Optum®) uses to conduct utilization review (UR) determinations concerning the appropriateness and/or medical necessity for reporting of established patient re-evaluations.
363	Therapies	The Application of Passive Therapeutic Modalities for Neuromusculoskeletal Disorders	To summarize OptumHealth Care Solution, Inc. (OptumHealth)?s assessment of the evidence-based applications of passive therapeutic modalities in the clinical management of common neuromusculoskeletal conditions or complaints.
366	Determinations	Denial of Services Not Covered By the Health Plan	To state the criteria supporting coverage denials that provide no criteria for the denial other than the service is not covered.
367	Determinations	Critical Data Elements	This policy lists and describes the application of critical data elements as a component of utilization review determinations.
388	Determinations	Range of Motion Testing	This policy describes the criteria used by Optum when rendering utilization review (UR) determinations regarding the medical necessity of range of motion testing when reported as a separate procedure.
392	Imaging/Testing	Diagnostic Spinal Ultrasound	This policy describes the position of OptumHealth Care Solutions, LLC (Optum®) regarding the application of diagnostic ultrasound in clinical practice for spine-related musculoskeletal conditions.
393	Therapies	Spinal Manipulation Under Anesthesia	This policy serves as the criterion for peer-reviewer decisions concerning spinal manipulation under anesthesia. The policy document summarizes the position of Optum® concerning the evidence-basis of services described by CPT code 22505, Manipulation of spine requiring anesthesia, any region. [Plain Language Summary]
449	Determinations	Maintenance/Custodial Care	This policy has been developed as the clinical criterion that describes the position of Optum® regarding the efficacy of maintenance or custodial care in the context of in-office services rendered by chiropractors, occupational and physical therapists. [Plain Language Summary]
473	Therapies	Nonsurgical Spinal Decompression Therapy	This policy has been developed as the clinical criterion that describes the position of Optum® regarding the efficacy, risks and burdens associated with the use of motorized traction devices for nonsurgical spinal decompression therapy. [Plain Language Summary]
474	Determinations	Patient Healthcare Records Documentation Requirements for Utilization Review and File Audits	This policy describes the elements of documentation that healthcare providers are required to include in patient medical records as well as recommended elements.
477	Administrative	Negotiated Services	This policy has been developed to describe the criteria that Optum® uses to conduct the negotiation of health care services with non-participating healthcare providers, when requested by client health plan members.
479	Determinations	Determining Homebound Status	This policy has been developed to describe the criteria that Optum® uses to conduct utilization review (UR) determinations concerning the appropriateness and/or medical necessity for providing skilled professional services in the home setting. This policy also serves as a basis for peer-to peer clinical discussions to determine the setting that will produce the safest and most efficacious outcomes.
483	Determinations	Kinesiology (Kinesio) Taping	This policy has been developed as the clinical criterion that describes the position of Optum® regarding the efficacy, effectiveness, risks and burdens associated with the use of kinesiology (kinesio) taping therapy. [Plain Language Summary]
486	Determinations	Skilled Care Services	This Policy has been developed as the clinical criterion that describes the position of Optum® regarding the determination of skilled care services when rendered by qualified health care providers. [Plain Language Summary]
489	Determinations	Dry Needling	This policy has been developed as the clinical criterion that describes the position of Optum regarding the effectiveness and safety associated with the use of dry needling therapy. [Plain Language Summary]
490	Determination	Spinal Manual Therapy for Non-Spinal Musculoskeletal Disorders	This policy has been developed as the clinical criterion that describes the position of Optum regarding the efficacy, effectiveness, risks, and burdens associated with the use of spinal manual therapy techniques for the treatment of non-spinal musculoskeletal disorders. [Plain Language Summary]
	Spine, Pain, and Joint (SPJ) Utilization Management Policy	Epidural Steroid Injections	This policy contains general information and indications for the use of epidural steroid injections.
	Spine, Pain, and Joint (SPJ) Utilization Management Policy	Facet Joint Interventions and Spinal Ablation Procedures	This policy contains general information and indications for the use of facet joint interventions and spinal ablation procedures.
	Spine, Pain, and Joint (SPJ) Utilization Management Policy	Epidural Spinal Cord Stimulator	This policy contains general information and indications for the use of epidural spinal cord stimulator devices.
	Spine, Pain, and Joint (SPJ) Utilization Management Policy	Sacroiliac Joint Interventions for Pain Relief	This policy contains general information and indications for sacroiliac joint interventions for pain relief.
496	Determinations	Medicare Chiropractic services	This policy has been developed to describe the criteria that Optum® uses to conduct utilization review for chiropractic services under Medicare.
497	Determinations	Medicare Outpatient skilled therapy (PT/OT/ST)	This policy has been developed to describe the criteria that Optum® uses to conduct utilization review for outpatient skilled therapy (PT/OT/ST) services under Medicare.
	Spine, Pain, and Joint (SPJ) Utilization Management Policy	ReActiv8 Implantable Neurostimulation System	This policy contains general information and coverage determination for the use of ReActiv8 Implantable Neurostimulation System