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.
https://consensus.nih.gov/1997/1997acupuncture107html.htm. Accessed April 24, 2020.
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 April 24, 2020.
American Academy of Medical Acupuncture (AAMA). General Information. Available at: http://www.medicalacupuncture.org/. Accessed April 24, 2020.
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. Accessed April 24, 2020.
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 April 24, 2020.
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. Accessed
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. (2016);6:CD001218.
Accessed April 24, 2020.
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 April 24, 2020.
National Institutes of Health, National Center for Complementary and Integrative Health (NCCIH). Acupuncture. Available at: https://nccih.nih.gov/health/acupuncture. Accessed Accessed April 24, 2020.
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 April 24, 2020.
NCCN Clinical Practice Guidelines in Oncology. Antiemesis, version 2.2020.
https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Accessed April 24, 2020.
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 April 24, 2020.
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. 03/02/2020. [Up to Date Web site]. Available at: http://www.uptodate.com [via subscription only]. Accessed April 24, 2020.
Up to Date. Treatment and outcome of nausea and vomiting of pregnancy. 04/09/2020. [Up to Date Web site]. Available at: http://www.uptodate.com [via subscription only]. Accessed April 24, 2020.
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 April 24, 2020.
Attachment A for a list of ICD-10-CM codes considered Medically Necessary for Acupuncture.
Policy: 11.14.02o:Trigger Point Injections
Policy: 12.00.03g:Complementary and Integrative Health Services