Latest Review Date: August 2023

Category: Ancillary Services

POLICY

For dates of service on or after October 31, 2022

I.  Needle Acupuncture: Initial Therapy    

Needle acupuncture (manual or electroacupuncture) may be considered medically necessary for the following indications:

• Treatment of chronic pain (defined as duration of at least six months), including treatment of episodic migraines and/or tension-type headaches; OR
• Prevention and treatment of nausea associated with surgery, chemotherapy, or pregnancy.

II.  Needle Acupuncture: Maintenance Therapy

• Maintenance therapy may be considered medically necessary when:
  • Patient meets medical necessity criteria above; AND
  • Acupuncture treatment has resulted in positive clinical response demonstrated by one or more of the following:
    • Chronic pain
      • Decreased use of pain medication (if applicable based on medication use); OR
      • Objectively measured improvement or stabilization in function (e.g., Neck Disability Index, Oswestry Disability Index, Pain Disability Index, and Roland Morris Back Pain Disability Questionnaire);
      • Nausea associated with surgery, chemotherapy, or pregnancy, including prevention of onset, decreased frequency, or decreased intensity.
• Needle acupuncture (manual or electroacupuncture) maintenance therapy is considered not medically necessary in all other situations.

III. Needle Acupuncture: Investigational Uses

Needle acupuncture is considered investigational for all other conditions including but not limited to the following due a lack of clinical evidence demonstrating an impact on improved health outcomes:

• Substance-related disorders
• Infertility
• Obesity/weight loss
• Fatigue
• Allergic rhinitis
• Asthma
• Acne
• Sexual dysfunction
• Recurrent pregnancy loss
• Insomnia
• Smoking cessation
• Depression
• Schizophrenia
• Anxiety
• Post-traumatic stress disorder

IV. Electrical Stimulation of Auricular Acupuncture Points: Investigational Uses

Electrical stimulation of auricular acupuncture points is considered investigational due to a lack of evidence demonstrating an impact on improved health outcomes.

Documentation Submission

Documentation supporting the medical necessity criteria described in the policy for maintenance therapy must be included. In addition, the following documentation must also be submitted:

• Clinical notes describing the following:
  1. Patient meets medical necessity criteria for initial acupuncture treatment
  2. Description of current treatment plan and outcomes including one of the following:
     • Chronic pain
       • Decreased use of pain medication (if applicable based on medication use); OR
       • Objectively measured improvement or stabilization in function (e.g., Neck Disability Index, Oswestry Disability Index, Pain Disability Index, and Roland Morris Back Pain Disability Questionnaire);
       • Nausea associated with surgery, chemotherapy, or pregnancy:
         • prevention of onset of nausea; OR
         • decreased frequency; OR
         • decreased intensity.

For dates of service prior to October 31, 2022

I.  Needle Acupuncture: Initial Therapy    

Needle acupuncture (manual or electroacupuncture) may be considered medically necessary for the following indications:

• Treatment of chronic pain (defined as duration of at least six months) when the following criteria have been met, prior to the beginning of acupuncture treatment:
  • A comprehensive history and physical evaluation of the patient has been completed to document etiology of the pain; AND
  • Conservative forms of multidisciplinary therapy (e.g., pharmacologic therapy, physical therapy, psychotherapy) have been tried and have failed to alleviate the pain.
• Prevention and treatment of nausea associated with surgery, chemotherapy, or pregnancy.

II.  Needle Acupuncture: Maintenance Therapy

• Maintenance therapy may be considered medically necessary when:
  • Patient meets medical necessity criteria above; AND
  • Acupuncture treatment has resulted in positive clinical response demonstrated by one of the following:
    • Decreased use of pain medication, OR
    • Objectively measured improvement in function (e.g., Neck Disability Index, Oswestry Disability Index, Pain Disability Index, and Roland Morris Back Pain Disability Questionnaire); OR
    • Improvement of function or stabilization of functional decline indicated by measures at the onset of acupuncture and measures at subsequent follow-up maintenance treatments.
• Needle acupuncture (manual or electroacupuncture) maintenance therapy is considered not medically necessary in all other situations.

III. Needle Acupuncture: Investigational Uses

Needle acupuncture is considered investigational for all other conditions including but not limited to the following due a lack of clinical evidence demonstrating an impact on improved health outcomes:

• Substance-related disorders
• Behavioral health conditions
• Infertility
• Obesity/weight loss
• Fatigue
• Allergic rhinitis
• Asthma
• Acne
• Sexual dysfunction
• Nausea due to conditions other than surgery, pregnancy or chemotherapy

IV. Electrical Stimulation of Auricular Acupuncture Points: Investigational Uses

Electrical stimulation of auricular acupuncture points is considered investigational due to a lack of evidence demonstrating an impact on improved health outcomes.

Documentation Submission

Documentation supporting the medical necessity criteria described in the policy for maintenance therapy must be included in the prior authorization, when prior authorization is required. In addition, the following documentation must also be submitted:

• Clinical notes describing the following:
  1. Patient meets medical necessity criteria for initial acupuncture treatment
  2. Description of current treatment plan and outcomes including one of the following:
     • Decreased use of pain medication, OR
     • Objectively measured improvement in function, function (e.g., Neck Disability Index, Oswestry Disability Index, Headache Index, Roland Morris, Promo6b Pain Index); OR
     • Stabilization of functional decline Stabilization of functional decline demonstrated valid and reliable functional measures with return maintenance visits to support functional declines and improvement with an initial trial of acupuncture and subsequent follow up maintenance treatments.

DESCRIPTION OF PROCEDURE OR SERVICE

Acupuncture involves the stimulation of anatomical points on the body using a variety of techniques. Acupuncture methods have been used to relieve pain, induce anesthesia, alleviate the symptoms of substance withdrawal, and to treat various disorders. The term "maintenance therapy" in context of this policy refers to therapy conducted after initial therapeutic goals of acupuncture have been achieved via objective measurement of symptom improvement or when no additional functional decline due to pain has occurred.

The acupuncture technique that has been most often studied involves penetrating the skin at specific points throughout the body with thin, solid, metallic needles that are manipulated by hand or by electrical stimulation, known as electroacupuncture. In needle acupuncture, the placement of needles into the skin is dictated by the location of meridians. These meridians are thought to mark patterns of energy flow throughout the human body.

Electrical stimulation of auricular acupuncture points is based on the theory that all acupuncture points are located on the external part of the ear and that each treated point triggers electrical impulses from the ear to the brain and then to the specific body part being treated. This technique differs from placement of manual acupuncture or electroacupuncture techniques which are based on the location of specific meridians as noted above.

Auricular electrical stimulation devices provide pulsed, low-intensity current to auricular acupuncture sites over several days. Auricular electrical stimulation devices have been cleared for marketing through the U.S. Food and Drug Administration (FDA) through the 510(k) process for use as an electroacupuncture device to stimulate appropriate auricular acupuncture points.  These include but are not limited to the P-Stim™ and E-pulse™.

BENEFIT APPLICATION

Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.

ITS: Covered if covered by the Participating Home Plan

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.

CURRENT CODING:

CPT Codes:

POLICY HISTORY

Reviewed and posted July 1, 2021.

August 2021: Annual review completed. No change to policy intent.

September 2022: Coverage updated for acupuncture (initial therapy) in the treatment of chronic pain: added “treatment of episodic migraines and/or tension-type headaches.” Coverage criteria previously required prior to initiation of therapy has been removed.  Added “nausea associated with surgery, chemotherapy, or pregnancy” as a covered indication for maintenance therapy. “Recurrent pregnancy loss, insomnia, smoking cessation, depression, schizophrenia, anxiety, post-traumatic stress disorder” added to investigational uses for needle acupuncture. Policy on draft September 16, 2022 through October 31, 2022.

September 2023: Annual review completed. Added code, 0783T to Current Coding section. No change to policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1.  The technology must have final approval from the appropriate government regulatory bodies;
2.  The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3.  The technology must improve the net health outcome;
4.  The technology must be as beneficial as any established alternatives;
5.  The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1.  In accordance with generally accepted standards of medical practice; and
2.  Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3.  Not primarily for the convenience of the patient, physician or other health care provider; and
4.  Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.