Latest Review Date: March 2025

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 but not limited to chronic pain from 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);
    • Decreased frequency or decreased intensity of 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™.

KEY POINTS

A Cochrane review by Linde et al (2016) included RCTs at least 8 weeks in duration that compared acupuncture with sham acupuncture, prophylactic medication treatment, and/or no acupuncture in patients with episodic migraines. Trials focusing on chronic migraine were excluded. The primary efficacy outcome was headache frequency, and the secondary outcome was the proportion of responders (at least a 50% reduction in migraine frequency). Twenty-one RCTs met reviewers’ selection criteria; all were parallel-group trials. Fifteen trials included a sham acupuncture control group, 5 had a prophylactic medication group, and 5 had a no acupuncture group (several trials had >2 arms). Acupuncture interventions were heterogeneous (e.g., number of sessions, length of sessions, standardized vs. individualized placement of needles). Risk of bias was assessed in 13 sham-controlled trials; all attempted blinding and the overall risk of bias was considered to be low.

Giovanardi et al (2020) completed a more recent systematic review and meta-analysis that evaluated the efficacy and safety of acupuncture versus pharmacological prophylaxis of migraine. The review included 9 RCTs, the majority of which were discussed in the Cochrane review by Linde et al (2016). Results were similar with the authors concluding that acupuncture is mildly more effective and much safer than medication for the prophylaxis of migraine.

Tastan et al (2018) published a comparative study of 3 treatments for migraines. Ninety patients were included in the study and assigned to the acupuncture group (n=30), hypnotherapy group (n=30), or pharmacotherapy group (n =30; acetaminophen 650 mg or 1300 mg was used). Visual analog scale (VAS) and Migraine Disability Assessment scores decreased significantly for all 3 groups after 3 months (p<.001). For acupuncture and hypnotherapy, the percentage reduction in the VAS score was significantly higher than pharmacotherapy at 3 months (p<.001). Also, the percentage reduction for the Migraine Disability Assessment score was significantly higher for acupuncture and hypnotherapy than pharmacotherapy (p=.007 and p=.002, respectively). The study was limited by its short follow-up time, lack of blinding, and lack of assessment of patients’ demographic characteristics.

Kolokotsios et al (2021) conducted a systematic review and meta-analysis of 15 trials (N=1267) that evaluated the effectiveness of acupuncture on headache intensity and frequency in patients with tension-type headache. The average number of acupuncture sessions per patient in these studies was 9 and the average duration of treatment was 5.5 weeks. Results revealed that headache frequency after the last treatment was not significantly lower in the acupuncture group versus the placebo/sham group (mean difference, -1.53; 95% CI, -4.73 to 1.67); however, there was a trend toward improvement in the frequency of headaches in the long term (p=.06). Additionally, the VAS score was slightly reduced in the acupuncture group as compared with control after the last treatment (mean difference, -0.29; 95% CI, -1.21 to 0.62; p=.53). Long term, acupuncture was associated with a significant reduction in VAS (mean difference, -0.41; 95% CI, -0.72 to -0.10; p=.009).

Mu et al (2020) published a Cochrane review which included 33 RCTs (N=8270) that assessed the effects of acupuncture compared to sham intervention, no treatment, or usual care for chronic nonspecific low back pain in adults with pain lasting more than 3 months without a specific etiology. The primary outcomes were pain, back-specific functional status, and quality of life. The authors concluded that acupuncture may not play a more clinically meaningful role than sham in relieving pain immediately after treatment or in improving quality of life in the short term, and acupuncture did not improve back function compared to sham in the immediate term. However, acupuncture was more effective than no treatment in improving pain and function in the immediate term.

A systematic review and meta-analysis by Lin et al (2024) evaluated acupuncture versus oral medications for acute and subacute low back pain. Fourteen studies were included (N= 1263); the results showed that acupuncture therapy was marginally more effective than oral medication in reducing pain (p< 0.00001; I2 = 92%; mean difference [MD] −1.17, 95% CI [−1.61 to −0.72]; moderate effect, extremely low-quality evidence). Tests like the Roland-Morris Disability Questionnaire (RMDQ), the Lumbar Range of Motion (LROM), and the Schober test were used to evaluate functional status. For RMDQ, acupuncture therapy demonstrated a statistically significant advantage over oral medication (p< 0.00001; I2 = 90%, standardized mean difference [SMD] − 1.42, 95% CI [− 2.22 to − 0.62]; large effect, very low-quality evidence).

Huang et al (2021) conducted a systematic review and meta-analysis that analyzed the efficacy and safety of acupuncture for the treatment of chronic spinal pain. The review included 22 RCTs with 2588 patients who had chronic neck pain, chronic low back pain, or sciatica for more than 3 months. Any type of acupuncture therapy was included in the systematic review/meta-analysis such as traditional acupuncture, electro-acupuncture, fire needling, auricular acupuncture, abdominal acupuncture, warm acupuncture, and bee venom acupuncture. Control interventions included usual care, no treatment, sham acupuncture, placebo, or pharmacologic therapies. The primary outcome was pain intensity. Overall, standard acupuncture was utilized in 16 studies, the duration of interventions ranged from 1 treatment to 8 weeks of treatment, and follow-up ranged from 2 weeks to 1 year after the final treatment. A pooled analysis revealed acupuncture to significantly improve chronic spinal pain as compared to sham acupuncture (weighted mean difference [WMD], -12.05; 95% CI, -15.86 to -8.24), usual care (WMD, -9.57; 95% CI, -13.48 to -9.44), and no treatment (WMD, -17.1; 95% CI, -24.83 to -9.37). Acupuncture was also associated with improvement in physical functioning at short-, intermediate-, and long-term follow-up.

Jin et al (2024) evaluated acupuncture therapy for nausea and vomiting during pregnancy in a systematic review and meta-analysis. There were 24 RCTs (N=2390 women) included in the analysis. Acupuncture was performed alone or in combination with the control group (e.g, sham acupuncture, placebo, no treatment, or Western medicine). Pregnancy-Unique Quantification of Emesis (PUQE) scores and ineffective rates were significantly lower with acupuncture plus WM than with WM alone (PUQE: MD, 1.95; 95% CI, 3.08 to 0.81; p =.0008, I2 =90%; 6 studies) (ineffective rates: RR, 0.27; 95% CI, 0.19 to 0.39; p<.00001; I2 = 7%; 16 studies). Along with a shorter period of stay, acupuncture plus Western medicine also led to a higher improvement in ketonuria and lower ratings on the Chinese Medicine Syndrome Scale and nausea and vomiting of pregnancy (NVP) QOL scale. When it came to lowering ineffective rates, acupuncture outperformed Western medicine (RR, 0.50; 95% CI 0.30 to 0.81; p =.006; I2 = 0%; 5 studies). Improvements in PUQE scores and ketonuria negative rates were similar across acupuncture and Western Medicine.

Zheng et al (2021) performed a systematic review and meta-analysis involving 10 trials (9 RCTs and 1 prospective cohort) that evaluated the effectiveness of acupuncture therapy after gynecologic surgery.  A total of 1075 women who had undergone gynecologic surgery with general anesthesia were included. Included studies evaluated the use of acupuncture and its derived techniques (eg, transcutaneous acupoint electrical stimulation, acupressure, and acupoint application) versus placebo or sham acupuncture. Primary outcomes of the analysis included the incidence of postoperative nausea and the incidence of postoperative vomiting. Results revealed that acupuncture therapy was associated with a significant reduction in the risk of developing postoperative nausea and postoperative vomiting by 48% (RR, 0.52; 95% CI, 0.44 to 0.61; p<.00001) and 42% (RR, 0.58; 95% CI, 0.49 to 0.68; p<.00001), respectively. There were no significant differences between groups with regard to the incidence of adverse effects (eg, bleeding and needle pain; p=.54). Acupuncture therapy was also significantly associated with a reduced rate of rescue antiemetic usage (p<.00001) and an increased degree of satisfaction with postoperative recovery (p<.0001). The authors concluded that acupuncture therapy is effective and safe for PONV prophylaxis in patients undergoing gynecologic surgery; however, a large, multicenter study is still required to compare the effects of acupuncture on preventing PONV with other noninvasive acupoint stimulation techniques.

Eccleston et al (2017) published a Cochrane review of interventions for reducing prescribed opioid use in patients with chronic non-cancer pain who had a treatment goal of reduction or cessation of opioid use. Selection criteria included RCTs comparing interventions with sham, active control, or usual care. One RCT on acupuncture was identified. It compared 6 weeks of electroacupuncture (n=17) with sham electroacupuncture (n=18). At the end of treatment, 64% of the electroacupuncture group and 46% of the sham group had reduced opioid consumption; the difference between groups was not statistically significant.

Two Cochrane reviews and 1 meta-analysis addressed acupuncture for treating nausea and vomiting in pregnancy. A 2023 RCT found greater efficacy of acupuncture, doxylamine-pyridoxine, and the combination compared with placebo in women with moderate or severe nausea and vomiting during early pregnancy. A 2024 meta-analysis found that acupuncture plus Western medicine may be a more beneficial treatment than Western medicine alone for nausea and vomiting associated with pregnancy. A third Cochrane review addressed chemotherapy-induced nausea and vomiting.

Hayes published a comparative effectiveness review (2021), and concluded:

“A large body of evidence suggests that acupuncture may offer some modest benefit with regard to improving rates of response and reducing frequency in patients with episodic or chronic tension-type headaches or episodic migraines. In addition to these potential benefits, acupuncture may help reduce analgesic use among patients, at least in the near term”.

For those who have episodic migraines who receive acupuncture, the evidence includes randomized controlled trials (RCTs), a nonrandomized comparative study, and systematic reviews. Pooled analyses of 15 sham-controlled trials on episodic migraine in a Cochrane review found significantly better outcomes with acupuncture, which were considered to be clinically significant. For those who have tension-type headaches who receive acupuncture, the evidence includes RCTs and systematic reviews. Pooled analyses in a Cochrane review on acupuncture for tension-type headaches consistently found statistically significant benefits of acupuncture compared with sham.

For those who have chronic pain who receive acupuncture, the evidence includes RCTs and systematic reviews. Pooled analyses of sham-controlled randomized trials on chronic low back pain in 2 different meta-analyses found improvements in pain up to 3 months. Pooled analyses from other meta-analyses found clinically meaningful improvement regarding pain or function among the acupuncture recipients compared with the group receiving other treatments. For individuals who have other pain-related conditions (e.g., shoulder pain, lateral elbow pain, carpal tunnel syndrome, cancer pain in adults, pain in endometriosis, pain in rheumatoid arthritis) who receive acupuncture, the evidence includes RCTs and systematic reviews of these trials. The RCTs were generally of low quality. One meta-analysis of 7 RCTs in cancer pain found better pain reduction with true acupuncture versus sham acupuncture. Another meta-analysis of 22 RCTs in patients with chronic spinal pain found acupuncture therapy to significantly improve pain as compared to sham acupuncture, usual care, or no treatment.

For those who have nausea or vomiting or are at high-risk of nausea or vomiting who receive acupuncture, the evidence includes RCTs and meta-analyses.  Several trials found that the acupuncture intervention was associated with a significantly lower incidence of acute vomiting during the next 24 hours.

For those who have opioid dependence who receive acupuncture, the evidence includes RCTs and systematic reviews. A Cochrane review identified a single RCT, which did not find a significant benefit from acupuncture in reducing opioid consumption in patients with chronic non-cancer-related pain. A narrative systematic review concluded that there is insufficient evidence from high-quality RCTs to draw conclusions about the efficacy of acupuncture in the treatment of opioid addiction.

Practice Guidelines and Position Statements

American College of Rheumatology

The guidelines from the American College of Rheumatology (2019) on the treatment of osteoarthritis conditionally recommend acupuncture for patients with hip, knee, and/or hand osteoarthritis. Guideline authors note that the evidence for efficacy of acupuncture in osteoarthritis remains a subject of controversy. The greatest number of positive trials with the largest effect sizes have been in patients with knee osteoarthritis. The authors conclude: "While the 'true' magnitude of effect is difficult to discern, the risk of harm is minor, resulting in the Voting Panel providing a conditional recommendation."

American College of Physicians

A guideline from the American College of Physicians (2017) strongly recommends nonpharmacologic therapy for the initial treatment of chronic low back pain: this may include "exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence)."

Department of Veterans Affairs/Department of Defense

The Department of Veterans Affairs/Department of Defense (2023) guideline on the primary care management of headache found insufficient evidence to recommend for or against acupuncture for the treatment of headache. According to guideline authors, "the quality of the evidence in the use of acupuncture was very low. The body of evidence had limitations, including a small sample size and confounders in the analysis, and the effect size was very small for the most robust outcome".

The Department of Veterans Affairs/Department of Defense (2020) guideline on the non-surgical management of hip and knee osteoarthritis found insufficient evidence to recommend for or against the use of acupuncture in this setting.

The Department of Veterans Affairs/Department of Defense (2022) guideline on the treatment of low back pain suggests offering acupuncture to patients with chronic low back pain. The authors state: "Acupuncture appears to have a small benefit for the reduction of pain for those with chronic LBP [low back pain] in the intermediate-term (3 to 12 months). The evidence from two SRs [systematic reviews] and one small RCT [randomized controlled trial] favored acupuncture over sham for the critical outcome of pain intensity." For acute low back pain, there was insufficient evidence to recommend for or against the use of acupuncture.

National Institute for Health and Care Excellence

The NICE (2012) guidance, updated in 2021, on the diagnosis and management of headaches in those over 12 years of age recommended a course of up to 10 sessions of acupuncture over 5 to 8 weeks for prophylactic treatment of chronic tension-type headaches. For migraines, the guidance recommended a course of up to 10 sessions of acupuncture over 5 to 8 weeks for prophylactic treatment if both topiramate and propranolol were unsuitable or ineffective.

The NICE (2016) guidance, updated in 2020, on the assessment and management of low back pain and sciatica in those over 16 years of age recommended not offering acupuncture for low back pain with or without sciatica.

North American Spine Society

The North American Spine Society (2020) guideline on low back pain states that "in patients with low back pain, there is conflicting evidence that acupuncture provides improvements in pain and function as compared to sham acupuncture." However, the guideline recommends acupuncture in addition to usual care in patients with chronic low back pain, stating that "addition of acupuncture to usual care is recommended for short-term improvement of pain and function compared to usual care alone."

Society for Integrative Oncology and American Society of Clinical Oncology

The Society for Integrative Oncology and the American Society of Clinical Oncology (ASCO) released joint guidance in 2022 on integrative approaches to managing pain in adults with cancer. The recommendations provided related to acupuncture are below:

• "Acupuncture should be offered to patients experiencing aromatase inhibitor-related joint pain in breast cancer (Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).
• Acupuncture may be offered to patients experiencing general pain or musculoskeletal pain from cancer (Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).
• Acupuncture may be offered to patients experiencing chemotherapy-induced peripheral neuropathy from cancer treatment (Evidence based-informal consensus, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).
• Acupuncture or acupressure may be offered to patients undergoing cancer surgery or other cancer-related procedures such as bone marrow biopsy (Evidence based-informal consensus, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak)."

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:

REFERENCES

1. Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guideline for the primary care management of headache. 2023; www.healthquality.va.gov/guidelines/pain/headache/VADoDHeadacheCPGFinal508.pdf.
2. Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guideline for the non-surgical management of hip & knee osteoarthritis. 2020; www.healthquality.va.gov/guidelines/CD/OA/VADoDOACPG.pdf.
3. Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guideline for diagnosis and treatment of low back pain. 2022; www.healthquality.va.gov/guidelines/pain/lbp/.
4. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95. Published 2022 Nov 4.
5. Eccleston C, Fisher E, Thomas KH, et al. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev. 2017;11(11):CD010323. Published 2017 Nov 13.
6. Giovanardi CM, Cinquini M, Aguggia M, et al. Acupuncture vs. Pharmacological Prophylaxis of Migraine: A Systematic Review of Randomized Controlled Trials. Front Neurol. 2020;11:576272. Published 2020 Dec 15.
7. Hayes Knowledge Center: Comparative effectiveness review of acupuncture for the treatment of episodic and chronic tension-type headache and episodic migraine: a review of reviews. October, 2021.
8. Huang JF, Zheng XQ, Chen D, et al. Can Acupuncture Improve Chronic Spinal Pain? A Systematic Review and Meta-Analysis. Global Spine J. 2021;11(8):1248-1265.
9. Jin B, Han Y, Jiang Y, Zhang J, Shen W, Zhang Y. Acupuncture for nausea and vomiting during pregnancy: A systematic review and meta-analysis. Complement Ther Med. 2024;85:103079.
10. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee [published correction appears in Arthritis Care Res (Hoboken). 2021 May;73(5):764.
11. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee [published correction appears in Arthritis Care Res (Hoboken). 2021 May;73(5):764.
12. Kolokotsios S, Stamouli A, Koukoulithras I, Plexousakis M, Drousia G. The Effectiveness of Acupuncture on Headache Intensity and Frequency in Patients With Tension-Type Headache: A Systematic Review and Meta-Analysis. Cureus. 2021;13(4):e14237. Published 2021 Apr 1.
13. Lin H, Wang X, Feng Y, et al. Acupuncture Versus Oral Medications for Acute/Subacute Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. Curr Pain Headache Rep. 2024;28(6):489-500.
14. Lin JG, Chan YY, Chen YH. Acupuncture for the treatment of opiate addiction. Evid Based Complement Alternat Med. 2012;2012:739045.
15. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016;2016(6):CD001218. Published 2016 Jun 28.
16. Mao JJ, Ismaila N, Bao T, et al. Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline. J Clin Oncol. 2022;40(34):3998-4024.
17. Mu J, Furlan AD, Lam WY, Hsu MY, Ning Z, Lao L. Acupuncture for chronic nonspecific low back pain. Cochrane Database Syst Rev. 2020;12(12):CD013814. Published 2020 Dec 11.
18. National Institute for Health and Care Excellence (NICE). Headaches in over 12s: diagnosis and management [CG150]. Published September 19, 2012. Updated December 17, 2021; www.nice.org.uk/guidance/cg150.
19. National Institute for Health and Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management [NG59]. Published November 30, 2016. Updated December 11, 2020; www.nice.org.uk/guidance/ng59.
20. North American Spine Society. Diagnosis and Treatment of Low Back Pain. 2020; www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LowBackPain.pdf.
21. Tastan K, Ozer Disci O, Set T. A Comparison of the Efficacy of Acupuncture and Hypnotherapy in Patients With Migraine. Int J Clin Exp Hypn. 2018;66(4):371-385.
22. Wen H, Chen R, Zhang P, et al. Acupuncture for Opioid Dependence Patients Receiving Methadone Maintenance Treatment: A Network Meta-Analysis. Front Psychiatry. 2021;12:767613. Published 2021 Dec 13.
23. Wu XK, Gao JS, Ma HL, et al. Acupuncture and Doxylamine-Pyridoxine for Nausea and Vomiting in Pregnancy : A Randomized, Controlled, 2 × 2 Factorial Trial. Ann Intern Med. 2023;176(7):922-933.

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.

August 2024: Annual review completed. No change to policy intent.

March 2025: Updates to Policy Statement- removed “treatment of” and added “but not limited to chronic pain from” to Needle Acupuncture: Initial Therapy chronic pain indication. Added Key Points and References sections. 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.