2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 82 Services that are covered for you What you must pay when you get these services in-network and out-of-network Chiropractic services $20 copayment for each Medicare-covered visit.†† Covered services include: · Manual manipulation of the spine to correct subluxation You pay these amounts until (when one or more of the bones of your spine move out you reach the out-of-pocket of position). Manual manipulation is a treatment that maximum. uses hands-on pressure to gently move your joints and tissues. Excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation, including: · Maintenance therapy. Chiropractic treatment is considered maintenance therapy when continuous ongoing care is no longer expected to provide clinical improvements and the treatment becomes supportive instead of corrective. · Extra charges when your chiropractor uses a manual, hand-held device to add controlled pressure during treatment. · X-rays, massage therapy, and acupuncture (unless the acupuncture is for the treatment of chronic low back pain). Routine chiropractic services‡ $15 copayment for each visit* Includes 24 visits per plan year. Please turn to Section 4 Routine chiropractic services of this chapter for more detailed information about this chiropractic benefit. There is no coinsurance, Colorectal cancer screening copayment, or deductible for a