Notification

Acupuncture (Independence)


Notification Issue Date: 10/02/2018

This version of the policy will become effective 01/01/2019.

The Company’s coverage position has changed from Benefit Contract Exclusion to Medically Necessary for the following conditions:

  • Headache (migraine and tension)
  • Post-operative nausea and vomiting
  • Chemotherapy-induced nausea and vomiting
  • Nausea of pregnancy
  • Low back pain
  • Pain from osteoarthritis of the knee and hip
  • Chronic neck pain

The following ICD-10 CM codes have been added to Attachment A of this policy:

G43.001, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.419, G43.501, G43.509, G43.511, G43.519, G43.601, G43.609, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.419, G43.501, G43.509, G43.511, G43.519. G43.601, G43.609, G43.611, G43.619, G43.701, G43.709, G43.711, G43.719, G43.801, G43.809, G43.811, G43.819, G43.821, G43.829, G43.831, G43.839, G43.901, G43.909, G43.911, G43.919, G44.201, G44.209, G44.211, G44.219, G44.221, G44.229, K91.0, M16.0, M16.10, M16.11, M16.12, M16.2, M16.30, M16.31, M16.32, M16.4, M16.50, M16.51, M16.52, M16.6, M16.7, M16.9, M17.0, M17.10, M17.11, M17.12, M17.2, M17.30, M17.31, M17.32, M17.4, M17.5, M17.9, M54.2, M54.5, O21.0, O21.1, O21.2, O21.8, O21.9, R11.2


Medical Policy Bulletin


Title:Acupuncture (Independence)

Policy #:12.00.01f

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

The provision of benefits for all services related to acupuncture is in accordance with the individual's benefit contract and varies by product and group. Therefore, individual member benefits must be verified. Coverage of acupuncture may be subject to coverage limits, existing contractual exclusions, and medical necessity criteria. Refer to the Cross References section for a list of policies that address services related to this topic.

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

MEDICALLY NECESSARY

Needle acupuncture (manual or with electrical stimulation) is considered medically necessary and, therefore, covered for the following conditions:
  • Headache (migraine and tension)
  • Post-operative nausea and vomiting
  • Chemotherapy-induced nausea and vomiting
  • Nausea of pregnancy
  • Low back pain
  • Chronic neck pain
  • Pain from osteoarthritis of the knee and hip

EXPERIMENTAL/INVESTIGATIONAL

Acupuncture for all other uses is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

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.
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 a therapeutic procedure performed by the insertion of one or more specially manufactured solid metallic needles into a specific location(s) on the body. The intent is to stimulate acupuncture points (thereby rebalancing the body's energy flow), with or without subsequent manual manipulation.

Acupuncture has been a key component of traditional Chinese medicine for centuries, most commonly used in the treatment of pain. According to a National Institutes of Health (NIH) consensus panel statement (1997), the general theory of acupuncture is based on the premise that there are patterns of energy flow called Qi (Chi) that flow through the body that are essential for health, and that disruptions of this flow are believed to be responsible for disease. Acupuncture may correct imbalances of flow at identifiable points close to the skin.

Several physiologic explanations of acupuncture’s mechanism of action have been proposed, including an analgesic effect from the release of endorphins or hormones, a biomechanical effect, and/or an electromagnetic effect.

The National Center for Complementary and Integrative Health (NCCIH) notes that results from a number of studies suggest that acupuncture may help ease types of pain that are often chronic such as low back pain, neck pain, and osteoarthritis (OA) of the knee, and that it may also help reduce the frequency of tension headaches and prevent migraine headaches. In addition, acupuncture has been proposed to treat a variety of other disorders including digestive, respiratory, neurologic, muscular, urinary, menstrual and reproductive disorders, as well as anxiety and stress disorders.

PEER-REVIEWED LITERATURE

For individuals who have episodic migraines headaches who receive acupuncture, the evidence includes randomized controlled trials (RCTs) and systematic reviews. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. Pooled analyses of 15 sham-controlled trials on episodic migraine headaches in a Cochrane review found significantly better outcomes with acupuncture, which were considered to be clinically significant. Pooled analyses of trials on acupuncture versus medication found a significant benefit of acupuncture at the end of treatment but not at the end of the follow-up period. The available evidence is sufficient to conclude that acupuncture could be associated with improved outcomes for individuals with episodic migraine headaches.

For individuals who have tension-type headaches who receive acupuncture, the evidence includes RCTs and systematic reviews. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. Pooled analyses in a Cochrane review on acupuncture for tension-type headaches consistently found statistically significant benefits of acupuncture compared with sham up to 5 to 6 months. The available evidence is sufficient to conclude that acupuncture could be associated with improved outcomes for individuals with tension-type headaches.

In a randomized controlled trial, Witt et al. (2006) evaluated the effectiveness of acupuncture in addition to routine care compared to routine care alone in individuals with chronic pain due to OA of the knee or hip. Individuals were randomly allocated to undergo 15 sessions of acupuncture in a 3-month period, or to a control group receiving no acupuncture. An additional arm that did not consent to randomization underwent acupuncture treatment. Clinical OA severity (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and health related quality of life (Short Form 36) were assessed at baseline and after 3 months and 6 months. At 3 months the WOMAC score had improved and quality of life improvements were more pronounced in the acupuncture group versus the control group (p<0.001). The outcome for individuals in the nonrandomized group were comparable to the randomized individuals who received acupuncture. Treatment success was maintained through 6 months. The clinical trial concluded that acupuncture plus routine care was associated with marked clinical improvement in individuals with chronic OA pain of the knee or hip.

In a randomized controlled trial, Scharf et al. (2006) evaluated the efficacy and safety of traditional Chinese acupuncture (TCA) compared with sham acupuncture (needling at defined nonacupuncture sites) and conservative therapy in individuals who had chronic pain for at least 6 months due to osteoarthritis (OA) of the knee (American College of Rheumatology [ACR] criteria and Kellgren-Lawrence score of 2 or 3). Interventions included up to 6 physiotherapy sessions and as-needed anti-inflammatory drugs plus 10 sessions of TCA, 10 sessions of sham acupuncture, or 10 physician visits within 6 weeks. Up to 5 additional sessions could be requested if the initial treatment was viewed as partially successful. The clinical trial concluded that compared with physiotherapy and as-needed anti-inflammatory drugs, addition of either TCA or sham acupuncture led to greater improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 26 weeks.

In a meta-analysis, Vickers et al. (2012) evaluated trials of acupuncture for four chronic pain conditions that included back and neck pain, osteoarthritis, and chronic headache. Twenty-nine of 31 eligible trials met criteria with a total of 17,922 individuals analyzed. The authors found statistically significant differences between both acupuncture versus sham and acupuncture versus no acupuncture control for all pain types studied (all p<0.001). The authors noted that although the data indicated that acupuncture was more than a placebo, the differences between true and sham acupuncture were relatively modest. The authors concluded, "Our results from individual patient data meta-analyses of nearly 18,000 randomized individuals in high-quality RCTs provide the most robust evidence to date that acupuncture is a reasonable referral option for individuals with chronic pain."

In a systematic review, Garcia et al. (2013) evaluated the effectiveness of acupuncture for symptom management in individuals with cancer. Prospective randomized clinical trials (RCT) evaluating acupuncture for symptom management in cancer care that involved needle insertion into acupuncture points were included, 41 RCTs met all inclusion criteria. The authors concluded that acupuncture is an appropriate adjunctive treatment for chemotherapy-induced nausea/vomiting, but did note that additional studies are needed. For other symptoms, efficacy remained undetermined due to high risk of bias among studies.

A 2018 AHRQ systematic review evaluated noninvasive nonpharmacological treatments for selected chronic pain conditions and acupuncture was included as an intervention associated with slightly improved function compared with usual care (pharmacological therapy or exercise).

Various professional societies and expert groups have issued guidance regarding Acupuncture. In 1997, the National Institutes of Health Consensus Development panel issued a statement addressing the use of acupuncture noting that there is clear evidence that needle acupuncture is efficacious for adult post-operative and chemotherapy-induced nausea and vomiting and probably for the nausea of pregnancy. In 2014, the Colorado Division of Workers' Compensation medical treatment guidelines on low back pain stated that "there is good evidence that acupuncture, true or sham, is superior to usual care for the reduction of disability and pain in individuals with chronic nonspecific low back pain, and that true and sham acupuncture are likely to be equally effective." In 2017, the American College of Physicians (ACP) clinical practice guideline recommended the use of acupuncture as a noninvasive treatment for adults with acute, subacute, or chronic low back pain.
References


Acupuncture. NIH Consens Statement 1997 Nov 3-5; 15(5): 1-34. Available at:
https://consensus.nih.gov/1997/1997acupuncture107html.htm. Accessed June 13, 2018.

Agency for Healthcare Research and Quality (AHRQ). Noninvasive nonpharmacological treatment for chronic pain: A systematic review. June 2018. Available at: https://effectivehealthcare.ahrq.gov/topics/nonpharma-treatment-pain/research-2018. Accessed on June 13, 2018.

American Academy of Medical Acupuncture (AAMA). General Information. Available at: http://www.medicalacupuncture.org/. Accessed May 17, 2018.

American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin No. 189: Nausea and vomiting of pregnancy . Obstet Gynecol. Jan 2018;131(1):e15-30. Accessed at: https://journals.lww.com/greenjournal/Fulltext/2018/01000/ACOG_Practice_Bulletin_No__189___Nausea_And.39.aspx. June 14, 2018.

Boelig RC, Barton SJ, Saccone G, et al. Interventions for treating hyperemesis gravidarum. Cochrane Database Syst Rev.(2016);5:CD010607.

Company Benefit Contracts.

Colorado Division of Workers' Compensation. Low back pain: medical treatment guidelines. Denver, CO: Colorado Division of Workers' Compensation; February 3, 2014. Available at: https://www.colorado.gov/pacific/sites/default/files/MTG_Ex1_LBP.pdf. Accessed June 13, 2018.

Garcia MK, McQuade J, Haddad R, et al. Systematic review of acupuncture in cancer care: a synthesis of the evidence. J Clin Oncol. 2013; 31(7): 952-60.

Lee A, Chan SKC, Fan LTY. Stimulation of the wrist acupuncture point PC6 for preventing postoperative nause and vomiting. Cochrane Database Syst Rev. (2015);11:CD003281.

Lim TK, Ma Y, Berger F, et al. Acupuncture and neural mechanism in the management of low back pain-an update. Medicines(Basel). June 2018;5(3):63. Accessed at: http://www.mdpi.com/2305-6320/5/3/63/htm#B311-medicines-05-00063. July 23, 2018.

Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. (2016);6:CD001218.

Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. (2016);4:CD007587.

Matthews A, Haas DM, O’Mathúna DP, et al. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. (2015);9:CD007575.

McParlin C, O’Donnell A, Robson SC, et al. Treatments for hyperemesis gravidarum and nausea and vomiting in pregnancy: a systematic review. JAMA 2016;316:1392–401.

Medical Devices: Acupuncture needle. 21 e-CFR Part 880, Federal Register §880.5580 June 2018. Available at: https://www.ecfr.gov/cgi-bin/text-idx?SID=6268493b638a1c519f37cbcbccf0a86d&mc=true&node=se21.8.880_15580&rgn=div8. Accessed June 21, 2018.

National Institutes of Health, National Center for Complementary and Integrative Health (NCCIH). Acupuncture. Available at: https://nccih.nih.gov/health/acupuncture. Accessed May 17, 2018.

National Institutes of Health, National Center for Complementary and Integrative Medicine (NCCIH). Acupuncture: In Depth. December 2007. (Updated January 2016). Available at: https://nccih.nih.gov/health/acupuncture/introduction. Accessed May 17, 2018.

NCCN Clinical Practice Guidelines in Oncology. Antiemesis, version 3.2018.
https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Accessed June 13, 2018.

Qaseem A, Wilt T, McLean R, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017; 166(7):514-30. Available at: http://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice. Accessed June 13, 2018.

Sator-Katzenschlager SM, Michalek-Sauberer A. P-Stim auricular electroacupuncture stimulation device for pain relief. Expert Rev Med Devices 2007 Jan;4(1):23-32.

Scharf HP, Mansmann U, Streitberger K, et al. Acupuncture and knee osteoarthritis: a three-armed randomized controlled trial. Ann Intern Med.2006; 145(1):12-20.

Up to Date. Acupuncture. 04/23/2018. [Up to Date Web site]. Available at: http://www.uptodate.com [via subscription only]. Accessed June 13, 2018.

Up to Date. Treatment and outcome of nausea and vomiting of pregnancy. 05/25/2018. [Up to Date Web site]. Available at: http://www.uptodate.com [via subscription only]. Accessed June 13, 2018.

Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012; 172(19): 1444-53.

Witt C, Jena S, Brinkhaus B, et al. Acupuncture in patients with osteoarthritis of the knee or hip: A randomized, controlled trial with an additional nonrandomized arm. Arthritis and Rheumatism. 2006; 54(11): 3485-93. Available at: https://onlinelibrary.wiley.com/doi/epdf/10.1002/art.22154. Accessed June 13, 2018.





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)

97810, 97811, 97813, 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)

REFER TO:

Attachment A for a list of ICD-10-CM codes considered Medically Necessary for Acupuncture.



HCPCS Level II Code Number(s)

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


Revenue Code Number(s)



0374 Anesthesia-acupuncture

2101 Alternative Therapy Services-Acupuncture

Coding and Billing Requirements


Cross References

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




Policy History

12.00.01f:
01/01/2019This version of the policy will become effective 01/01/2019.

The Company’s coverage position has changed from Benefit Contract Exclusion to Medically Necessary for the following conditions:
  • Headache (migraine and tension)
  • Post-operative nausea and vomiting
  • Chemotherapy-induced nausea and vomiting
  • Nausea of pregnancy
  • Low back pain
  • Pain from osteoarthritis of the knee and hip
  • Chronic neck pain

The following ICD-10 CM codes have been added to Attachment A of this policy:

G43.001, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.419, G43.501, G43.509, G43.511, G43.519, G43.601, G43.609, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.419, G43.501, G43.509, G43.511, G43.519. G43.601, G43.609, G43.611, G43.619, G43.701, G43.709, G43.711, G43.719, G43.801, G43.809, G43.811, G43.819, G43.821, G43.829, G43.831, G43.839, G43.901, G43.909, G43.911, G43.919, G44.201, G44.209, G44.211, G44.219, G44.221, G44.229, K91.0, M16.0, M16.10, M16.11, M16.12, M16.2, M16.30, M16.31, M16.32, M16.4, M16.50, M16.51, M16.52,M16.6, M16.7, M16.9, M17.0, M17.10, M17.11, M17.12, M17.2, M17.30, M17.31, M17.32, M17.4, M17.5, M17.9, M54.2, M54.5, O21.0, O21.1, O21.2, O21.8, O21.9, R11.2

12.00.01e
03/14/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Acupuncture.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 01/01/2019
Version Issued Date: 01/02/2019
Version Reissued Date: N/A

Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.