3. Treatment guidelines: Initial treatment: A total of 3-4 visits over 2 weeks may be considered medically necessary

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1 HCT Medical Policy Acupuncture for the Treatment of Pain Policy # HCT112 Current Effective Date: 2/21/2015 Medical Policies are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Medical Policy contains only a partial, general description of plan or program benefits and does not constitute a contract. HealthyCT does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of HealthyCT or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Medical Policy may be updated and therefore is subject to change. Policy Statement Acupuncture may be considered medically necessary as a treatment for pain management when all of the following criteria are met: 1. Documented symptoms of pain present on a daily basis resulting in an objective functional impairment (i.e. decreased performance of ability to perform activities of daily living); and 2. Diagnosis of one of the following conditions: Chronic low back pain Migraine and tension headaches Osteoarthritis of the knee and hip 3. Treatment guidelines: Initial treatment: A total of 3-4 visits over 2 weeks may be considered medically necessary Continued treatment: A total of up to 8-12 additional visits over 4-6 weeks may be considered medically necessary when there is documented reduction of pain, medication use and objective functional improvement. Page 1 of 10

2 Maintenance therapy in the absence of progressive functional improvement is considered NOT medically necessary. 4. Acupuncture is NOT covered for any other clinical condition or diagnosis that includes but is not limited to all of the following: any other type of acute or chronic pain; cancer pain; carpal tunnel syndrome pain; epicondylitis; fibromyalgia; neck and upper back pain; and shoulder pain including rotator cuff syndrome Overview The term acupuncture describes a family of procedures involving the stimulation of points on the body using a variety of techniques and is as a form of complementary and alternative medicine (CAM) therapy in the United States. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. Acupuncture theory is based on the premise that energy, called "Qi", travels along prescribed pathways or meridians within the body and is responsible for maintaining good health by providing homeostatic regulation of vital body function. Disturbances in the flow of Qi, either excesses or deficiencies, are thought to result in disease. The exact mechanism of action of acupuncture has not been explained in Western medical terms however, it is theorized that acupuncture modulates pain transmission and the pain response by activation of the endogenous nociceptive system. Acupuncture is one of the key components of traditional Chinese medicine that has been practiced in China and other Asian countries for thousands of years. Scientific Rationale Evidence in the published, peer-reviewed scientific literature indicates that acupuncture is appropriate in a specific subset of individuals for pain management of certain conditions that include hip and knee joint osteoarthritis, low back pain and tension or migraine headaches. The evidence is insufficient to indicate whether acupuncture is effective in treating cancer pain, carpal tunnel syndrome pain, fibromyalgia, lateral elbow pain, neck and upper back pain, shoulder pain, and other types of acute or chronic pain. Page 2 of 10

3 Several Cochrane reviews have been published that evaluated the efficacy of acupuncture for carpal tunnel syndrome, peripheral joint osteoarthritis, lateral elbow pain, shoulder and neck pain, tension and migraine headaches; fibromyalgia and cancer pain. Sham-controlled trials showed statistically significant benefits in patients with osteoarthritis. In patients with frequent episodic or chronic tension-type headaches, acupuncture could be a valuable non-pharmacological tool. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects in patients with migraine headaches. There was insufficient evidence to judge whether acupuncture is effective in treating cancer pain in adults, carpal tunnel pain, fibromyalgia, lateral elbow pain, shoulder or neck pain due to small sample size, scarcity of studies for each comparison and lack of an ideal sham acupuncture that weakened the level of evidence. A 2012 National Center for Complementary and Alternative Medicine (NCCAM) funded study, employing individual patient data meta-analyses and published in the Archives of Internal Medicine conducted an analysis of individual patient data from 29 high-quality randomized controlled trials (RCTs), including a total of 17,922 people. These trials investigated the use of acupuncture for back and neck pain, osteoarthritis, shoulder pain, or chronic headache. In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P <.001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, ), 0.16 (95% CI, ), and 0.15 (95% CI, ) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, ), 0.57 (95% CI, ), and 0.42 (95% CI, ) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias. The authors concluded that acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture. 21 A large meta-analysis of acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee was published in This study found that in a sensitivity analysis of satisfactory and good quality studies, most studies were of acupuncture (11 trials) or musclestrengthening exercise (9 trials); both interventions were statistically significantly better than standard care, with acupuncture being statistically significantly better than muscle-strengthening exercise (standardized mean difference: 0.49, 95% credible interval ). The authors concluded that their meta-analysis indicated that acupuncture can be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term. 5 Page 3 of 10

4 A large systematic review evaluated the evidence for the effectiveness of acupuncture for nonspecific low back pain (LBP). Twenty-three trials (n = 6359) were included and classified into 5 types of comparisons, 6 of which were of high quality. There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief. There is strong evidence that acupuncture can be a useful supplement to other forms of conventional therapy for nonspecific LBP, but the effectiveness of acupuncture compared with other forms of conventional therapies still requires further investigation. The researchers concluded that acupuncture versus no treatment, and as an adjunct to conventional care, should be advocated in the European Guidelines for the treatment of chronic LBP. 24 A 2010 Agency for Healthcare Research and Quality (AHRQ) Technology Assessment systematically review the efficacy, effectiveness, cost-effectiveness, and harms of acupuncture in management of back, neck, and/or thoracic pain. Acupuncture for chronic nonspecific low back pain was associated with significantly lower pain intensity than placebo but only immediately post-treatment (VAS: -0.59, 95 percent CI: -0.93, -0.25). However, acupuncture was not different from placebo in post-treatment disability, pain medication intake, or global improvement in chronic nonspecific low back pain. Acupuncture did not differ from sham-acupuncture in reducing chronic non-specific neck pain immediately after treatment (VAS: 0.24, 95 percent CI: -1.20, 0.73). Acupuncture was superior to no treatment in improving pain intensity (VAS: -1.19, 95 percent CI: 95 percent CI: -2.17, -0.21), disability (PDI), functioning (HFAQ), well-being (SF-36), and range of mobility (extension, flexion), immediately after the treatment. In general, trials that applied sham-acupuncture tended to produce negative results (i.e., statistically non-significant) compared to trials that applied other types of placebo (e.g., TENS, medication, laser). Results regarding comparisons with other active treatments (pain medication, mobilization, laser therapy) were less consistent. Acupuncture was more cost-effective compared to usual care or no treatment for patients with chronic back pain. 1 Related Codes CPT CODES Acupuncture, one or more needles without electrical stimulation; initial 15 minutes of personal one-onone contact with the patient Acupuncture, one or more needles without electrical stimulation; each additional 15 minutes of personal one-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) Acupuncture, one or more needles with electrical stimulation; initial 15 minutes of personal one-on-one contact with the patient Acupuncture, one or more needles with electrical stimulation; each additional 15 minutes of personal one- one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) Page 4 of 10

5 ICD.9 CODES Lumbago Chronic pain due to trauma Other Chronic Post-OP pain Other chronic pain Migraine with aura, without mention of intractable migraine without mention of status Migraine with aura, with intractable migraine, so stated, without mention of status Migraine with aura, without mention of intractable migraine with status Migraine with aura, with intractable migraine, so stated, without mention of status Migraine without aura, without mention of intractable migraine without mention of status Migraine without aura, with intractable migraine, so stated, without mention of status Migraine without aura, without mention of intractable migraine with status Migraine without aura, with intractable migraine, so stated, with status Variants of migraine, not elsewhere classified, without mention of intractable migraine without mention of status Variants of migraine, not elsewhere classified, with intractable migraine, so stated, without mention of status Variants of migraine, not elsewhere classified, without mention of intractable migraine with status Variants of migraine, not elsewhere classified, with intractable migraine, so stated, with status Hemiplegic migraine, without mention of intractable migraine without mention of status Hemiplegic migraine, with intractable migraine, so stated, without mention of status Hemiplegic migraine, without mention of intractable migraine with status Hemiplegic migraine, with intractable migraine, so stated, with status Menstrual migraine, without mention of intractable migraine without mention of status Menstrual migraine, with intractable migraine, so stated, without mention of status Menstrual migraine, without mention of intractable migraine with status Menstrual migraine, with intractable migraine, so stated, with status Persistent migraine aura without cerebral infarction, without mention of intractable migraine without mention of status Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, without mention of status Persistent migraine aura without cerebral infarction, without mention of intractable migraine with status Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, with status Page 5 of 10

6 Persistent migraine aura with cerebral infarction, without mention of intractable migraine without mention of status Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, without mention of status Persistent migraine aura with cerebral infarction, without mention of intractable migraine with status Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, with status Chronic migraine without aura, without mention of intractable migraine without mention of status Chronic migraine without aura, with intractable migraine, so stated, without mention of status Chronic migraine without aura, without mention of intractable migraine with status Chronic migraine without aura, with intractable migraine, so stated, with status Other forms of migraine, without mention of intractable migraine without mention of status Other forms of migraine, with intractable migraine, so stated, without mention of status Other forms of migraine, without mention of intractable migraine with status Other forms of migraine, with intractable migraine, so stated, with status Migraine, unspecified, without mention of intractable migraine without mention of status Migraine, unspecified, with intractable migraine, so stated, without mention of status Migraine, unspecified, without mention of intractable migraine with status Migraine, unspecified, with intractable migraine, so stated, with status Tension headache Osteoarthrosis localized primary involving pelvic region and thigh Osteoarthrosis localized primary involving lower leg Osteoarthrosis localized secondary involving pelvic region and thigh Osteoarthrosis localized secondary involving lower leg Osteoarthrosis localized not specified whether primary or secondary involving pelvic region and thigh Osteoarthrosis localized not specified whether primary or secondary involving lower leg Osteoarthrosis unspecified whether generalized or localized involving pelvic region and thigh Osteoarthrosis unspecified whether generalized or localized involving lower leg ICD.10 Codes M54.5 Lumbago G89.21 Chronic pain due to trauma G89.28 Other Chronic Post-Op pain G89.29 Other chronic pain G Migraine without aura, without mention of intractable migraine with mention of status Page 6 of 10

7 G Migraine without aura, without mention of intractable migraine without mention of status G Migraine without aura, with intractable migraine, so stated, with status G Migraine without aura, with intractable migraine, so stated, without mention of status G Migraine with aura, without mention of intractable migraine with status G Migraine with aura, without mention of intractable migraine without mention of status G Migraine with aura, with intractable migraine so stated, with status G Migraine with aura, with intractable migraine, so stated, without mention of status G Hemiplegic migraine without mention of intractable migraine with status G Hemiplegic migraine without mention of intractable migraine without mention of status G Hemiplegic migraine with intractable migraine, so stated, with status G Hemiplegic migraine with intractable migraine, so stated, without mention of status G Persistent migraine aura without cerebral infarction, without mention of intractable migraine, with status G Persistent migraine aura without cerebral infarction, without mention of intractable migraine without mention of status G Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, with status G Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, without mention of status G Persistent migraine aura with cerebral infarction, without mention of intractable migraine with status G Persistent migraine aura with cerebral infarction, without mention of intractable migraine without mention of status G Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, with status G Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, without mention of status G Chronic migraine without aura, without mention of intractable migraine with status G Chronic migraine without aura, without mention of intractable migraine without mention of status G Chronic migraine without aura, with intractable migraine, so stated, with status G Chronic migraine without aura, with intractable migraine, so stated, without mention of status G Other migraine, not intractable, with status G Other migraine, not intractable, without status G Other migraine, intractable, with status G Other migraine, intractable without status Page 7 of 10

8 G Menstrual migraine, without mention of intractable migraine with status G Menstrual migraine, without mention of intractable migraine without mention of status G Menstrual migraine, with intractable migraine, so stated, with status G Menstrual migraine, with intractable migraine, so stated, without mention of status G Migraine, unspecified, without mention of intractable migraine with status G Migraine, unspecified, without mention of intractable migraine without mention of status G Migraine, unspecified, with intractable migraine, so stated, with status G Migraine, unspecified, with intractable migraine, so stated, without mention of status G Tension headache M16.0 Bilateral primary osteoarthritis of hip M16.10 Unilateral primary osteoarthritis, unspecified hip M16.11 Unilateral primary osteoarthritis, right hip M16.12 Unilateral primary osteoarthritis, left hip M16.2 Bilateral osteoarthritis resulting from hip dysplasia M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip M16.4 Bilateral post-traumatic osteoarthritis of hip M16.50 Unilateral post-traumatic osteoarthritis, unspecified hip M16.51 Unilateral post-traumatic osteoarthritis, right hip M16.52 Unilateral post-traumatic osteoarthritis, left hip M16.6 Other bilateral secondary osteoarthritis of hip M16.7 Other unilateral secondary osteoarthritis of hip M16.9 Osteoarthritis of hip, unspecified M17.0 Bilateral primary osteoarthritis of knee M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.2 Bilateral post-traumatic osteoarthritis of knee M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee M17.31 Unilateral post-traumatic osteoarthritis, right knee M17.32 Unilateral post-traumatic osteoarthritis, left knee M17.4 Other bilateral secondary osteoarthritis of knee M17.5 Other unilateral secondary osteoarthritis of knee M17.9 Osteoarthritis of knee, unspecified Page 8 of 10

9 References 1. Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment. Number 194. Complementary and Alternative Therapies for Back Pain II. October Available at: 2. American Academy of Orthopedic Surgeons (AAOS). Treatment of Osteoarthritis of the Knee. Evidence-Based Guideline. 2nd Edition. May 18, Available at: 3. Berman BM, Langevin HM, Witt CM, et al. Acupuncture for chronic low back pain. New England Journal of Medicine. 2010;363(5): Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine. 2009;169(9): Corbett MS, Rice SJ, Madurasinghe V, et al. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis Cartilage. 2013; 21(9): Endres HG, Böwing G, Diener HC, et al. Acupuncture for tension-type headache: a multicentre, sham-controlled, patient- and observer-blinded, randomized trial. J Headache Pain. 2007; 8(5): Cummings M. Modellvorhaben Akupunktur a summary of the ART, ARC and GERAC trials. Acupuncture in Medicine. 2009;27(1): Deare JC, Zheng Z, Xue CC, et al. Acupuncture for treating fibromyalgia. Cochrane Database Syst Rev. 2013;(5):CD Furlan A, Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. Acupuncture and dryneedling for low back pain. Cochrane Database Syst Rev Jan 25; (1): CD Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W. Acupuncture for lateral elbow pain (Cochrane Review). Cochrane Database Syst Rev 2002;(1):CD Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Cochrane Database Syst Rev Apr 18;(2):CD Hochberg MC, Altman RD, April KT, et al.; American College of Rheumatology. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012; 64(4): Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache. Cochrane Database Syst Rev. 2009;(1):CD Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev Jan 21;(1):CD Page 9 of 10

10 15. Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DA, Berman BM, Bouter LM. Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst Rev Jan 20;(1):CD National Center for Complementary and Alternative Medicine (NCCAM). NCCAM Pub No.: D404 Date Created: December 2007 Last Updated: July Accessed at: O'Connor D, Marshall S and Massy-Westropp N. Non-surgical treatment (other than steroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;(1):CD Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in Cochrane Database Syst Rev. 2011;(1):CD Trinh KV, Graham N, Gross AR, et al. Acupuncture for neck disorders. Cochrane Database Syst Rev, :CD Vickers AJ, Linde K. Acupuncture for chronic pain. JAMA. 2014;311(9): Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Archives of Internal Medicine. 2012;172(19): Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K, Willich SN. Acupuncture in patients with osteoarthritis of the knee or hip: A randomized, controlled trial with an additional nonrandomized arm. Arthritis Rheum Oct 30;54(11): Witt CM, Jena S, Brinkhaus B, et al. Acupuncture for patients with chronic neck pain. Pain. 2006;125(1 2): Yuan J, Purepong N, Kerr DP, et al. Effectiveness of acupuncture for low back pain: a systematic review. Spine. 2008;33(23):E887 E900. Document History Date Action 2/21/2015 Original Version Approved 08/11/2015 ICD.9/ICD.10 codes added Page 10 of 10

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