Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Acupuncture
Policy #:MA12.004a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

MEDICALLY NECESSARY

Acupuncture (manual or with electrical stimulation) for chronic low back pain of up to 12 sessions in a 90-day period is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has chronic low back pain lasting 12 weeks or longer.
  • The chronic low back pain is nonspecific, in that it has no identifiable systemic cause (e.g., not associated with metastatic, inflammatory, infectious disease).
  • The chronic low back pain is not associated with surgery.
  • The chronic low back pain is not associated with pregnancy.

An additional eight sessions may be considered medically necessary and, therefore, covered for individuals demonstrating an improvement. No more than 20 acupuncture sessions may be administered annually.

Acupuncture (manual or with electrical stimulation) must be discontinued if the individual is not improving or is regressing.

NOT COVERED

All types of acupuncture (manual or with electrical stimulation), including dry needling, for any indication other than chronic low back pain, is not covered by the Company because this service is not covered by Medicare.
Acupuncture (manual or with electrical stimulation) beyond 20 sessions is not covered by the Company because this service is not covered by Medicare.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Modifier KX must be reported when submitting a claim for acupuncture session 13 through 20.
Policy Guidelines

BENEFIT APPLICATION

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA regulates acupuncture needles and requires that they are sterile and labeled for single use only.

Description

Acupuncture is the selection and manipulation of specific acupuncture points by a variety of needling and non-needling techniques.


Acupuncture has been a key component of traditional Chinese medicine for centuries, most commonly used in the treatment of pain. While there is a diversity of theoretical models and techniques that are all described as acupuncture, all models and forms seek to treat symptoms and conditions through either the insertion of needles or "needling" at specifically chosen points on the body, or other "non-needling" techniques focused on these points.

Modern medical acupuncturists choose anatomically and physiologically important treatment points which may include both traditional acupuncture points and other non-traditional fixed points. More attention is focused on the tissue level (e.g., muscle rather than skin) and the type and amount of stimulation given.

There are several variations to traditional acupuncture, including shallow needling, intradermal needling, or intramuscular needling with or without a sensation of numbness, tingling, electrical sensation, fullness, distension, soreness, warmth, or itching felt by a patient around an acupuncture point. Acupuncturists may additionally seek a sensation of tenseness or dragging to the needles obtained by twirling, plucking or thrusting of acupuncture needles. There are also numerous variations of manually or electrically stimulated "needling" techniques, as well as multiple "non-needling" acupuncture techniques.

The mechanism of action of analgesia secondary to acupuncture is unclear, possibly multimodal. However, there are some physiologic effects that have been noted with its use. For example, it is thought that the immediate analgesic effects of acupuncture may be dependent on neural (nerve) innervation. Acupuncture has also been shown to induce the release of endogenous opioids in various parts of the brain. Local tissue effects, including release of adenosine at the site of needle stimulation, have also been observed, as have increases in local blood flow. Other modes of action have been reported, including local and myofascial trigger point needling effects, segmental pain effects, extrasegmental pain effects, and central regulatory effects.


References

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 30.3.3 Acupuncture for Chronic Low Back Pain [CMS Web site]. 01/21/2020. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=373&ncdver=1&bc=AAAAQAAAAAAA&. Accessed May 13, 2020.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Publication 100-04: Medicare claims processing. Transmittal 10128. Acupuncture for Chronic Low Back Pain (cLBP). [CMS Web site]. Original: 05/08/2020. Available at: https://www.cms.gov/files/document/r10128CP.pdf. Accessed May 15, 2020.

Centers for Medicare & Medicaid Services (CMS). Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N). 01/21/2020. Available at: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295. Accessed February 11, 2020.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

20560, 20561, 97810, 97811, 94813, 97814


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

ACUPUNCTURE IS MEDICALLY NECESSARY WHEN REPORTED WITH THE DIAGNOSIS CODES LISTED IN ATTACHMENT A


HCPCS Level II Code Number(s)



S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with patient


Revenue Code Number(s)


MEDICALLY NECESSARY

2101 Alternative Therapy Services-Acupunture

NOT COVERED

0374 Anesthesia-acupuncture



Misc Code

MODIFIER:


THE FOLLOWING MODIFIER MUST BE REPORTED WHEN SUBMITTING A CLAIM FOR ACUPUNCTURE SESSIONS 13 THROUGH 20

KX Requirements specified in the medical policy have been met




Coding and Billing Requirements


Cross References

Attachment A: Acupuncture
Description: ICD-10 CM Codes Eligible to be Reported for Acupuncture







Policy History

REVISIONS FROM MA12.004a:
01/21/2020This version of the policy will become effective 01/21/2020. The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits.

The following billing requirement has been incorporated into this policy to convey the following:
    • Modifier KX must be reported when submitting a claim for acupuncture session 13 through 20.

  • The following Attachment has been added to this policy:

    Attachment A: ICD-10 CM Codes Eligible to be Reported for Acupuncture

  • REVISIONS FROM MA12.004:
    01/21/2020This version of the policy will become effective 01/21/2020. The following new policy has been developed to address a new benefit that requires medical necessity criteria.

    In accordance with a Centers for Medicare & Medicaid Services (CMS) decision memo, the Company’s coverage position for Acupuncture has changed from standard benefit contract exclusion to Medically Necessary for chronic low back pain.

    The following CPT codes have been added to this policy:

    20560, 20561, 97810, 97811, 97813, 97814

    The following HCPCS code has been added to this policy:

    S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with patient

    The following revenue code has been added to this policy as Medically Necessary:

    2101 Alternative Therapy Services-Acupunture

    The following revenue code has been added to this policy as Not Covered:

    0374 Acupuncture (anesthesia related)




    Version Effective Date: 01/21/2020
    Version Issued Date: 07/07/2020
    Version Reissued Date: N/A