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Acupuncture
MA12.004c

Policy

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.

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.

Subject to the terms and conditions of the applicable Evidence of Coverage, acupuncture is covered under the medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. Additional visits for acupuncture may be available based on the member's Evidence of Coverage.

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. Although 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 that may include both traditional acupuncture points and other nontraditional 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 & 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 April 24, 2023. 

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Publication 100-03: Medicare National Coverage Determinations. Transmittal 10337 Acupuncture for Chronic Low Back Pain (cLBP). [CMS Web site]. 08/27/2020. Available at: r10337ncd.pdf (cms.gov)​. Accessed April 24, 2023. 

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 April 24, 2023. ​

Coding

CPT Procedure Code Number(s)
20560, 20561, 97810, 97811, 94813, 97814
ICD - 10 Procedure Code Number(s)
N/A
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

Modifiers

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

Policy History

Revisions From​ MA12.004c:​
​02/21/2024
​This policy has been reissued in accordance with the Company's annual review process.​
​01/01/2024

​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
​05/17/2023
​The policy has been reviewed and reissued to communicate the Company’s continuing position on Acupuncture.
​08/24/2022

​The policy has been reviewed and reissued to communicate the Company’s continuing position on Acupuncture.
10/01/2021

This policy has been identified for the ICD-10 code update, effective 10/01/2021.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following ICD-10 code has been deleted from Attachment A of this policy:
M54.5 Low back pain​

​The following ICD-10 cods have been added to Attachment A of this policy:
M54.50 Low back pain, unspecified
M54.51 Vertebrogenic low back pain
M54.59 Other low back pain​

Revisions From MA12.004b:
05/05/2021

This policy has been reissued in accordance with the Company's annual review process.​​

​01/01/2021

​This version of the policy will become effective 01/01/2021. The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits.

The following statement has been incorporated into the guidelines section of this policy to convey the following:


Subject to the terms and conditions of the applicable Evidence of Coverage, acupuncture is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.  Additional visits for acupuncture may be available based on the member'​s Evidence of Coverage.


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)

10/1/2021
10/1/2021
2/21/2024
MA12.004
Medical Policy Bulletin
Medicare Advantage
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.