Clinical Policy: Acupuncture
Reference Number: [Link].92 Coding Implications
Last Review Date: 09/19 Revision Log
See Important Reminder at the end of this policy for important regulatory and legal
information.
Description
Acupuncture involves the manual and/or electrical stimulation of thin, solid, metallic needles
inserted into the skin. Acupuncture has been studied for the treatment of many conditions, but
some of the more common and studied indications include pain, nausea and vomiting,
hypertension, chronic obstructive pulmonary disease, allergic rhinitis and addictive behavior.
Policy/Criteria
I. It is the policy of health plans affiliated with Centene Corporation® that, when a covered
benefit under the member’s benefit plan contract, needle acupuncture is medically necessary
when provided by a licensed acupuncturist or other appropriately licensed practitioner for
whom acupuncture is within the practitioner’s scope of practice and who has specific
acupuncture training or credentialing and any of the following conditions:
A. Postoperative or chemotherapy induced nausea and vomiting;
B. Nausea and vomiting of pregnancy;
C. Chronic low back, neck, or shoulder pain;
D. Chronic migraines or moderate to severe chronic tension headaches, defined as headaches
>14 days per month for more than 3 months;
E. Pain from clinically diagnosed osteoarthritis of the knee.
An initial course of 6 visits over 1 month is considered medically necessary. If improvement
in the condition occurs following the initial course of treatment, an additional 6 visits over 2
months is considered medically necessary to maintain improvement.
II. All other indications are considered experimental/investigational and not medically
necessary.
Background
Acute conditions typically are treated 2 to 3 times a week for two to three weeks then frequency
is gradually reduced until treatment is no longer needed. Generally treatment will last for 2 to 3
months. There is insufficient evidence in studies to establish a defined treatment protocol for
any condition.
Acupuncture is an ancient treatment originating in China approximately 2000 years ago. It is
one of the oldest medical procedures in the world. It is a form of complementary and alternative
medicine (CAM) that has been more commonly practiced in the United States since 1971.
Acupuncture theory is largely grounded in two major Chinese philosophies, Confucianism and
Taoism. The two philosophies emphasize the importance of nature and for humans to integrate
and abide by these laws rather than to resist them. The goal of the clinician is to maintain the
body’s harmonious balance both internally and in relation to the external environment. It is
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Acupuncture
believed treatment should not be solely symptom focused, so treatment is usually very
individualized and two patients with the same symptoms often do not get the same treatment.
Three important concepts of acupuncture are qi, yin/yang, and the Five Elements: wood, water,
fire, earth, and metal. Qi is often translated as “vital energy”. It is felt to permeate all things,
may assume different forms, and travel through meridians located on the body. Disturbances in
the flow of qi, such as stagnant, depleted, collapsed or rebellious, are believed to cause disease.
Yin and yang are complementary opposites. Yin represents more material, dense states of matter
and yang represents more immaterial, rarefied states of matter. The relationship between the two
is dynamic and cyclic. The acupuncturist must employ a series of qualitative assessments to
establish a patient’s present balance of yin and yang. The Five Elements represent different
basic processes, qualities or phases of a cycle. Each can generate or counteract another element.
Most vital organs, acupuncture meridians, emotions, and other health-related variable are
assigned an element, providing a global description of the balancing dynamics seen in each
person.
These principles are used by the acupuncturist to diagnose and treat individuals based on the
nature of the imbalance. The aim is to shift the constitution towards balance with the use of
various interventions, acupuncture being one important option.
The diagnostic evaluation of the acupuncturist may be extensive and complex, incorporating
assessment of practically everything, including skin, complexion, bones, channels, smells,
sounds, mental state, preferences, emotions, demeanor, and body build. Once the diagnosis is
established, fine metal needles are inserted into precisely defined points to correct disruption in
harmony. Needles are removed after being in place for 10 to 15 minutes while the patient lies
relaxed. Treatments can occur one to two times a week and the total number of sessions is
variable dependent on the condition, disease severity and chronicity.
There are many proposed models for the mechanism of action of the effects of acupuncture;
however the data have been either too inconsistent or inadequate to draw significant conclusions.
The theory in regards to the analgesic effect of acupuncture, associates the neurotransmitter
effects such as endorphin release at both the spinal and supraspinal levels. Functional MRI
studies have demonstrated various physiologic effects, associating acupuncture points with
changes in brain MRI signals. Another theory is that acupuncture points are associated with
anatomic locations of loose connective tissue.
Evidence from a number of randomized, blinded, placebo-controlled studies indicate that
acupoint stimulation can be effective in the management of postoperative nausea and vomiting,
particularly in women, with mixed results in pediatric populations. Acupoint stimulation for
women undergoing chemotherapy also reduced nausea and vomiting in some studies, but no
effect was reported in a study involving both men and women. The evidence regarding
alleviation of morning sickness by acupoint stimulation is limited, less rigorous than for
postoperative nausea and vomiting, and ambiguous.
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Recent data on acupuncture for postoperative dental pain is limited, but earlier evidence
indicated promising results for this use. Data was most promising for pain relief following tooth
extraction.
There are a number of randomized controlled trials that establish improvement in headache
frequency, intensity, response, use of relief medication and quality of life relative to usual care
and relief treatment only. However, the trials failed to demonstrate that acupuncture is more
effective than sham acupuncture. Results were ambiguous regarding efficacy of acupuncture
relative to prophylactic drug treatment. There was insufficient evidence available to conclude
the efficacy of acupuncture compared with nonpharmacological interventions.
Acupuncture for osteoarthritis pain appears to be effective, particularly for pain in the knee.
Recent literature has shown relief of pain and improved function in osteoarthritis of the knee for
patients treated with acupuncture.
Acupuncture has been studied for a variety of other reasons, but studies and evidence does not
currently support its use for indications such as, but not limited to, arm pain, temporomandibular
joint dysfunction, menstrual cramps and fibromyalgia.
Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered
trademark of the American Medical Association. All CPT codes and descriptions are copyrighted
2019, American Medical Association. All rights reserved. CPT codes and CPT descriptions are
from the current manuals and those included herein are not intended to be all-inclusive and are
included for informational purposes only. Codes referenced in this clinical policy are for
informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage.
Providers should reference the most up-to-date sources of professional coding guidance prior to
the submission of claims for reimbursement of covered services.
CPT®* Description
Codes
97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of
personal one-on-one contact with the patient
97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15
minutes of personal one-on-one contact with the patient, with reinsertion of needles(s)
97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of
personal one-on-one contact with the patient
97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15
minutes of personal one-on-one contact with the patient, with reinsertion of needles(s)
ICD-10-CM Diagnosis Codes that Support Coverage Criteria
+ Indicates a code(s) requiring an additional character
ICD-10-CM Code Description
G43.001-G43.919 Migraine
G44.221- G44.229 Chronic tension- type headache
M17.0-M17.9 Osteoarthritis of knee
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ICD-10-CM Code Description
M25.511-M25.519 Pain in shoulder
M50.00-M54.9+ Other dorsopathies
O21.0-O21.9 Excessive vomiting in pregnancy
R11.0-R11.2+ Nausea and vomiting
Reviews, Revisions, and Approvals Date Approval
Date
Bibliography reviewed and updated 11/14 12/14
Reworded medically necessary timeframes. No criteria changes made 01/15
Reformatted criteria, adopted new template 12/15 12/15
Reference reviewed and no criteria changes made
Integrated with Health Net acupuncture policy. Removed (adults and 10/16 11/16
children) from I.A; removed acute post-operative dental pain; maintained
neck and shoulder pain, and only osteoarthritis of knee. Did not incorporate
list of investigational procedures since it is not all inclusive.
References reviewed and updated. Changed continuation criteria to remove 11/17 11/17
statement that continued treatment after the initial 2 months is not medically
necessary.
References reviewed and updated. 09/18 09/18
References reviewed and updated. Specialist review. 08/19 09/19
References
1. Ahn AC. Acupuncture. In: UpToDate, Aronson MD (Ed), UpToDate, Waltham, MA, 2014.
Accessed September 21, 2019.
2. American Society of Anesthesiologists. Practice guidelines for chronic pain management.
Anesthesiology 2010; 112:1-1.
3. Aukerman G, Knutson D, Miser WF. Management of the acute migraine headache. Am Fam
Physician. 2002 Dec 1;66(11):2123-2131.
4. Hayes Health Technology Brief. Acupuncture for treatment of chronic obstructive
pulmonary disease (COPD). Lansdale, PA: Hayes, Inc. ©2006-2014 Winifred S. Hayes, Inc.
August 5, 2013, updated June 30, 2015. Archived Sept 5,2016.
5. Hayes Health Technology Assessment. Acupuncture for treatment of shoulder pain or
chronic neck pain: A review of the reviews. Lansdale, PA: Hayes, Inc. ©2006-2014
Winifred S. Hayes, Inc. August 22, 2018.
6. Hayes Health Technology Assessment. Acupuncture for the prevention or treatment of
nausea and vomiting: A review of the reviews. Lansdale, PA: Hayes, Inc. ©2006-2014
Winifred S. Hayes, Inc. Sept 19, 2018.
7. Hayes Healthl Technology Assessment. Acupuncture for treatment of fibromyalgia.
Lansdale, PA: Hayes, Inc. © 2006-2014 Winifred S. Hayes, Inc. August 28, 2018.
8. Hochberg MC, et al. American College of Rheumatology 2012 recommendations for the use
of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and
knee. Arthritis Care & Research. 2012 April 4;64(4):465-474.
9. Kelly RB. Acupuncture for pain. Am Fam Physician. 2009 Sep 1;80(5):481-484.
10. Kemper KJ. Complementary and alternative medicine in pediatrics. In: UpToDate, Drutz JE
(Ed), UpToDate, Waltham, MA, 2015. Accessed September 21 2019.
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11. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for
migraine prophylaxis. Cochrane Database Syst Rev. 2009;(1):CD001218.
12. MacPherson H, Tilbrook H, Richmond S, et al. Alexander Technique Lessons or
Acupuncture Sessions for Persons With Chronic Neck Pain. Annals of Internal Medicine.
2015 November 3; 163 (9).
13. National Center for Complementary and Alternative Medicine (NCCAM). Acupuncture for
pain. Last updated January 2016. [Link]
[Link]?nav=gsa
14. National Headache Foundation. Chronic Migraine, 2013.
[Link]
15. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual
patient data meta-analysis. Archives of Internal Medicine. September 10, 2012; Epub ahead
of print.
16. Hayes Comparative Effectiveness Review of Acupuncture for the Treatment of Episodic and
Chronic Tension Headache and Episodic Migraine: A Review of the Reviews. Sept 10, 2018
17. American College of Obstetricians and Gynecologist. ACOG Practice Bulletin. Number 189.
Nausea and Vomiting of Pregnancy. January 2019
18. WHO recommendation on interventions for the relief of nausea during pregnancy. 28
March 2018.
Important Reminder
This clinical policy has been developed by appropriately experienced and licensed health care
professionals based on a review and consideration of currently available generally accepted
standards of medical practice; peer-reviewed medical literature; government agency/program
approval status; evidence-based guidelines and positions of leading national health professional
organizations; views of physicians practicing in relevant clinical areas affected by this clinical
policy; and other available clinical information. The Health Plan makes no representations and
accepts no liability with respect to the content of any external information used or relied upon in
developing this clinical policy. This clinical policy is consistent with standards of medical
practice current at the time that this clinical policy was approved. “Health Plan” means a health
plan that has adopted this clinical policy and that is operated or administered, in whole or in part,
by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.
The purpose of this clinical policy is to provide a guide to medical necessity, which is a
component of the guidelines used to assist in making coverage decisions and administering
benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage
decisions and the administration of benefits are subject to all terms, conditions, exclusions and
limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy,
contract of insurance, etc.), as well as to state and federal requirements and applicable Health
Plan-level administrative policies and procedures.
This clinical policy is effective as of the date determined by the Health Plan. The date of posting
may not be the effective date of this clinical policy. This clinical policy may be subject to
applicable legal and regulatory requirements relating to provider notification. If there is a
discrepancy between the effective date of this clinical policy and any applicable legal or
regulatory requirement, the requirements of law and regulation shall govern. The Health Plan
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retains the right to change, amend or withdraw this clinical policy, and additional clinical
policies may be developed and adopted as needed, at any time.
This clinical policy does not constitute medical advice, medical treatment or medical care. It is
not intended to dictate to providers how to practice medicine. Providers are expected to exercise
professional medical judgment in providing the most appropriate care, and are solely responsible
for the medical advice and treatment of members. This clinical policy is not intended to
recommend treatment for members. Members should consult with their treating physician in
connection with diagnosis and treatment decisions.
Providers referred to in this clinical policy are independent contractors who exercise independent
judgment and over whom the Health Plan has no control or right of control. Providers are not
agents or employees of the Health Plan.
This clinical policy is the property of the Health Plan. Unauthorized copying, use, and
distribution of this clinical policy or any information contained herein are strictly prohibited.
Providers, members and their representatives are bound to the terms and conditions expressed
herein through the terms of their contracts. Where no such contract exists, providers, members
and their representatives agree to be bound by such terms and conditions by providing services to
members and/or submitting claims for payment for such services.
Note: For Medicaid members, when state Medicaid coverage provisions conflict with the
coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence.
Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical
policy.
Note: For Medicare members, to ensure consistency with the Medicare National Coverage
Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs,
and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this
clinical policy. Refer to the CMS website at [Link] for additional information.
©2016 Centene Corporation. All rights reserved. All materials are exclusively owned by
Centene Corporation and are protected by United States copyright law and international
copyright law. No part of this publication may be reproduced, copied, modified, distributed,
displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise
published without the prior written permission of Centene Corporation. You may not alter or
remove any trademark, copyright or other notice contained herein. Centene® and Centene
Corporation® are registered trademarks exclusively owned by Centene Corporation.
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