Acupuncture (NCD 30.3) – Medicare Advantage Policy …

1 Acupuncture Page 1 of 15 unitedhealthcare Medicare Advantage Policy Guideline Approved 05/12/2022 Proprietary Information of unitedhealthcare . Copyright 2022 United HealthCare Services, Inc. unitedhealthcare Medicare Advantage Policy Guideline Acupuncture Guideline Number: Approval Date: May 12, 2022 Terms and Conditions Table of Contents Page Policy Summary .. 1 Applicable Codes .. 2 Definitions .. 11 Questions and Answers .. 11 References .. 11 Guideline History/Revision Information .. 13 Purpose .. 14 Terms and Conditions .. 15 Policy Summary See Purpose Item/Service Description General Acupuncture is the selection and manipulation of specific Acupuncture points by a variety of needling and non-needling techniques. Indications and Limitations of Coverage Nationally Covered Indications Effective for claims with dates of service on and after January 21, 2020, Acupuncture is only covered for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act (the Act).

2 Refer to the National Coverage Determination section for specific coverage criteria. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances: For the purpose of this decision, cLBP is defined as: o Lasting 12 weeks or longer; o Nonspecific, in that it has no identifiable systemic cause ( , not associated with metastatic, inflammatory, infectious, etc. disease); o Not associated with surgery; and o Not associated with pregnancy An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 Acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is regressing. Physicians (as defined in 1861(r)(1)) of the Social Security Act (the Act) may furnish Acupuncture in accordance with applicable state requirements. Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs) (as identified in 1861(aa)(5) of the Act), and auxiliary personnel may furnish Acupuncture if they meet all applicable state requirements and have: Related Medicare Advantage Coverage Summary Complementary and Alternative Medicine Acupuncture Page 2 of 15 unitedhealthcare Medicare Advantage Policy Guideline Approved 05/12/2022 Proprietary Information of unitedhealthcare .

3 Copyright 2022 United HealthCare Services, Inc. A masters or doctoral level degree in Acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and A current, full, active, and unrestricted license to practice Acupuncture in a State, Territory, or Commonwealth ( , Puerto Rico) of the United States, or District of Columbia Auxiliary personnel furnishing Acupuncture must be under the appropriate level of supervision of a physician, physician assistant (PA), or nurse practitioner (NP)/clinical nurse specialist (CNS) required by our regulations at 42 CFR and Nationally Non-Covered Indications Medicare reimbursement for Acupuncture , as an anesthetic, or as an analgesic or for other therapeutic purposes, may not be made unless the specific indication is excepted. All indications for Acupuncture outside of NCD section remain non-covered.

4 After careful reconsideration of its initial non-coverage determination for Acupuncture , the Centers for Medicare & Medicaid Services (CMS) concludes that there is no convincing evidence for the use of Acupuncture for pain relief in patients with fibromyalgia or osteoarthritis. Study design flaws presently prohibit assessing Acupuncture s utility for improving health outcomes. Accordingly, CMS determines that Acupuncture is not considered reasonable and necessary for the treatment of fibromyalgia or osteoarthritis within the meaning of 1862(a)(1) of the Social Security Act, and the national non-coverage determination for Acupuncture for fibromyalgia and osteoarthritis continues. All types of Acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare . Applicable Codes The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive.

5 Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and guidelines may apply. CPT Code Description 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) 20561 Needle insertion(s) without injection(s); 3 or more muscles 64999 Unlisted procedure, nervous system 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 re-insertion of needle(s) (List separately in addition to code for primary procedure) 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.

6 With electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) CPT is a registered trademark of the American Medical Association Modifier Description KX Requirements specified in the medical Policy have been met Acupuncture Page 3 of 15 unitedhealthcare Medicare Advantage Policy Guideline Approved 05/12/2022 Proprietary Information of unitedhealthcare . Copyright 2022 United HealthCare Services, Inc. Diagnosis Code Description Flatback syndrome, lumbar region Flatback syndrome, lumbosacral region Postural lordosis, lumbar region Postural lordosis, lumbosacral region Lordosis, unspecified, lumbar region Lordosis, unspecified, lumbosacral region Other idiopathic scoliosis, lumbar region Other idiopathic scoliosis, lumbosacral region Other secondary scoliosis, lumbar region Other secondary scoliosis, lumbosacral region Adult osteochondrosis of spine, lumbar region Adult osteochondrosis of spine, lumbosacral region Spondylolysis, lumbar region Spondylolysis, lumbosacral region Spondylolisthesis, lumbar region Spondylolisthesis, lumbosacral region Fusion of spine, lumbar region Fusion of spine, lumbosacral region Other recurrent vertebral dislocation, lumbar region Other recurrent vertebral dislocation.

7 Lumbosacral region Other specified deforming dorsopathies, lumbar region Other specified deforming dorsopathies, lumbosacral region Other spondylosis with myelopathy, lumbar region Other spondylosis with radiculopathy, lumbar region Other spondylosis with radiculopathy, lumbosacral region Spondylosis without myelopathy or radiculopathy, lumbar region Spondylosis without myelopathy or radiculopathy, lumbosacral region Other spondylosis, lumbar region Other spondylosis, lumbosacral region Spinal stenosis, lumbar region without neurogenic claudication Spinal stenosis, lumbar region with neurogenic claudication Spinal stenosis, lumbosacral region Ankylosing hyperostosis [Forestier], lumbar region Ankylosing hyperostosis [Forestier], lumbosacral region Kissing spine, lumbar region Kissing spine, lumbosacral region Traumatic spondylopathy, lumbar region Traumatic spondylopathy, lumbosacral region Other specified spondylopathies, lumbar region Other specified spondylopathies, lumbosacral region Intervertebral disc disorders with myelopathy, lumbar region Intervertebral disc disorders with radiculopathy, lumbar region Acupuncture Page 4 of 15 unitedhealthcare Medicare Advantage Policy Guideline Approved 05/12/2022 Proprietary Information of unitedhealthcare .

8 Copyright 2022 United HealthCare Services, Inc. Diagnosis Code Description Intervertebral disc disorders with radiculopathy, lumbosacral region Other intervertebral disc displacement, lumbar region Other intervertebral disc displacement, lumbosacral region Other intervertebral disc degeneration, lumbar region Other intervertebral disc degeneration, lumbosacral region Schmorl's nodes, lumbar region Schmorl's nodes, lumbosacral region Other intervertebral disc disorders, lumbar region Other intervertebral disc disorders, lumbosacral region Spinal instabilities, lumbar region Spinal instabilities, lumbosacral region Other specified dorsopathies, lumbar region Other specified dorsopathies, lumbosacral region Radiculopathy, lumbar region Radiculopathy, lumbosacral region Sciatica, right side Sciatica, left side Lumbago with sciatica, right side Lumbago with sciatica.

9 Left side Low back pain (Deleted 09/30/2021) Vertebrogenic low back pain (Effective 10/01/2021) Other low back pain (Effective 10/01/2021) Wedge compression fracture of unspecified lumbar vertebra, initial encounter for closed fracture (Deleted 04/01/2022) Wedge compression fracture of unspecified lumbar vertebra, initial encounter for open fracture (Deleted 04/01/2022) Wedge compression fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing (Deleted 04/01/2022) Wedge compression fracture of unspecified lumbar vertebra, subsequent encounter for fracture with delayed healing (Deleted 04/01/2022) Wedge compression fracture of unspecified lumbar vertebra, subsequent encounter for fracture with nonunion (Deleted 04/01/2022) Wedge compression fracture of unspecified lumbar vertebra, sequela (Deleted 04/01/2022) Stable burst fracture of unspecified lumbar vertebra, initial encounter for closed fracture (Deleted 04/01/2022) Stable burst fracture of unspecified lumbar vertebra, initial encounter for open fracture (Deleted 04/01/2022) Stable burst fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing (Deleted 04/01/2022) Stable burst fracture of unspecified lumbar vertebra, subsequent encounter for fracture with delayed healing (Deleted 04/01/2022) Stable burst fracture of unspecified lumbar vertebra, subsequent encounter for fracture with nonunion (Deleted 04/01/2022) Stable burst fracture of unspecified lumbar vertebra, sequela (Deleted 04/01/2022) Acupuncture Page 5 of 15 unitedhealthcare Medicare Advantage Policy Guideline Approved 05/12/2022 Proprietary Information of unitedhealthcare .

10 Copyright 2022 United HealthCare Services, Inc. Diagnosis Code Description Unstable burst fracture of unspecified lumbar vertebra, initial encounter for closed fracture (Deleted 04/01/2022) Unstable burst fracture of unspecified lumbar vertebra, initial encounter for open fracture (Deleted 04/01/2022) Unstable burst fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing (Deleted 04/01/2022) Unstable burst fracture of unspecified lumbar vertebra, subsequent encounter for fracture with delayed healing (Deleted 04/01/2022) Unstable burst fracture of unspecified lumbar vertebra, subsequent encounter for fracture with nonunion (Deleted 04/01/2022) Unstable burst fracture of unspecified lumbar vertebra, sequela (Deleted 04/01/2022) Other fracture of unspecified lumbar vertebra, initial encounter for closed fracture (Deleted 04/01/2022)