Medical Affairs Policy

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1 Service: Acupuncture Therapy PUM Medical Affairs Policy Medical Policy Committee Approval 03/16/18 Effective Date 07/01/18 Prior Authorization Needed Yes-if not an exclusion of the health plan Note: Acupuncture is often a specific exclusion of the member s health plan. Consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, medical.policies@wpsic.com. Description: Acupuncture is a therapeutic procedure that involves the strategic placement of needles to stimulate specific anatomical locations of the body, with the goal of relieving pain or treating disease. The scientific literature regarding the effectiveness of acupuncture continues to be insufficient, conflicting, and from uncontrolled studies, small case series, case reports, and anecdotal information. Some randomized trials suggest that acupuncture and sham acupuncture may have similar efficacy. Flaws in study design and reporting, the heterogeneity of treatment methods, clinical differences between trials, and lack of clear measurable outcomes continue to prevent conclusions about the efficacy and long-term outcomes. Further studies with better methodological quality are still needed. Reports regarding safety conclude that acupuncture provided by a certified acupuncturist is generally considered safe, if appropriate sterile techniques are followed. Consequently, there are professional society recommendations that patients interested in or open to acupuncture may be referred for a trial of acupuncture when the availability of safe alternatives is limited. Page 1 of 5

2 Indications of Coverage: In the absence of health plan exclusions, specific coverage indications or visit limits, a maximum of twelve (12) acupuncture treatments will be approved in a consecutive 12- month period. Limitations of Coverage: A. Review contract and endorsements for exclusions and prior authorization or benefit requirements. B. More than twelve acupuncture treatments is considered not medically necessary. C. Acupressure wristbands are non-prescription devices that are considered experimental, investigational, and unproven to affect health outcomes. Documentation Required: Office notes: Treatment plan showing specific treatment goals, expected number and frequency of treatment visits, and objective signs/ measures documenting efficacy of treatment. References: 1. Agency for Healthcare Research and Quality (AHRQ). Acupuncture for fibromyalgia. Technology assessment Jun. Available at: Accessed: 14 Dec Agency for Healthcare Research and Quality (AHRQ). Acupuncture for osteoarthritis. Technology assessment Jun. Available at: 14 Dec Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD): Acupuncture. NCD Baltimore, MD. Effective date: N/A. Available at: Accessed: 12 Dec Ernst E. Acupuncture - a critical analysis. Journal of Internal Medicine. 2006; 259(2): Ernst E. Acupuncture: what does the most reliable evidence tell us? J Pain Symptom Manage Apr; 37(4): Page 2 of 5

3 6. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. The Cochrane Database of Systematic Reviews 2006 Issue Hayes Medical Technology Directory. Acupuncture for the Treatment of Pain. Lansdale, Pa: Hayes, Inc.; 2006 Winifred S. Hayes, Inc Jan. Updated January 7, Archived Feb 20, Lewis K, Abdi S. Acupuncture for lower back pain: a review. Clin J Pain Jan; 26(1): Madsen MV, Gotzsche PC, Hrobjartsson A. Acupuncture treatment for pain: systematic review of randomized clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ Jan 27; 338:a Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med Apr 19; 142(8); National Center for Complementary and Alternative Medicine. Acupuncture for Pain. Updated: August Available at: nccam.nih.gov/health/acupuncture/acupuncture-for-pain.htm. Accessed: 14 Dec National Institutes of Health (NIH). Acupuncture. Consensus statement online Nov 3-5; 15(5):1-34. Available at: Consensus.nih.gov/1997/1997Acupuncture107html.htm. Accessed: 5 Jan Matthews A, Dowswell T, Haas DM, Doyle M, O'Mathúna DP. Interventions for nausea and vomiting in early pregnancy. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD DOI: / CD pub2. Assessed as up to date June Available at Accessed 6 Jan, Hayes Medical Technology Directory. Acupuncture and Acupressure for the Treatment of Nausea and Vomiting. June 14, Annual Review: May 21, 2014, Archived July 15, UpToDate. Treatment and outcome of nausea and vomiting of pregnancy. Literature review current through: Jan 2018 This topic last updated: Jan 17, UpToDate. Complementary and alternative therapies for cancer. Literature review current through: Dec This topic last updated: Aug 31, Page 3 of 5

4 17. UpToDate. Acupuncture. Literature review current through Jan Topic last updated Apr 20, UpToDate Treatment of Urinary incontinence in women. Literature review current through Jan Topic last updated Jan 25, Acupuncture. MCG Ambulatory Care 22nd Ed. A-0329 (AC) Acupuncture. 20. InterQual Clinical Evidence Summary. Copyright Acupuncture. 21. Hayes Medical Technology Directory. Acupuncture for Assisted Reproduction. Publication Date July 15, Annual Review June 5, 2014, June 05, Archived Aug 15, Hayes Medical Technology Directory. Acupuncture for Neck and Shoulder Pain. Publication Date Dec 27, Annual Review Feb 3, 2014, Archived Jan 27, Hayes Medical Technology Directory. Acupuncture for Treatment of Low Back Pain. Publication Date Oct 21, Annual Review Sept 8, 2014, Archived Nov 21, Hayes Health Technology Brief P-stim Auricular Electroacupuncture for Pain Management. Publication date Dec 31, 2012 Annual review Dec 10, 2014, Archived Jan 31, Hayes Technology Brief Acupuncture for Treatment of Chronic Obstructive Pulmonary Disease (COPD). Publication Date: August 5, 2013 Annual Review: June 30, 2015, Archived Sep 03, WPS / Arise Review History: Implemented 04/04/14, 04/17/15, 07/01/16, 07/01/17, 07/01/18 Reviewed 03/13/15, 03/11/16, 03/17/17, 03/16/18 Revised 03/07/14, 03/17/17, 03/16/18 Developed Medical Policy 03/07/14, 03/13/15, 03/11/16, 03/17/17, 03/16/18 Committee Approval Note: For review/revision history prior to 2014 see previous Medical Policy or Coverage Policy Bulletin Approved by the Medical Director Page 4 of 5

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