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HealthPartners

Coverage criteria policies

Acupuncture

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Prior authorization is not required for Acupuncture.

Coverage

Acupuncture is generally covered, if the member has an acupuncture benefit, per the indications listed below. Due to variations in member contracts, please check with Member Services for information regarding specific coverage for this service.

Indications that are covered

  1. Acupuncture treatment is generally limited to the following conditions:
    1. As an analgesia for medical procedures;
    2. Chronic pain syndromes, including but not limited to:
      1. Neuromusculoskeletal conditions (e.g., neck, back, extremity pain, radicular syndromes, myofacial pain syndromes, fibromyalgia syndromes);
      2. Headaches (chronic or recurrent, tension or migraine)
    3. Nausea (e.g., following chemotherapy; associated with pregnancy)
    4. PMS or menstrual disorders
  2. For patients with a new condition there should be documented improvement in the following areas that are relevant to the condition being treated.
    1. Severity/intensity, frequency and duration of main symptom; and
    2. General fatigue, lack of energy, strength or endurance; inability to complete a normal day’s obligations/tasks; and
    3. Mobility, agility, range of motion, ability to sit/stand/walk; and
    4. Sleep disturbance: difficulty falling or staying asleep, waking too early, not rested upon waking in the morning; and
    5. Decreased quality of life: negative mood, poor coping ability or emotional resiliency; significant relationships strained.

Indications that are not covered

  1. Smoking (tobacco) cessation.
  2. Other conditions not listed in this policy.
  3. Maintenance care is not covered per the member contract.

Definitions

Acupuncture is based on the premise that energy flows within the body along channels. There are 14 main channels, some associated with a specific body organ or subsidiary channels. In acupuncture treatment, fine, thin specialized needles are inserted along the channels. The needles are manipulated, with the aim of restoring the energy flow to a state of balance. The intention is that the patient will achieve an improved state of health.

Chronic Pain is defined as persistent pain which can be either continuous or recurring, and of at least 3 months duration and intensity to adversely affect a patient’s well-being, level of function and quality of life. The goals of treatment are an emphasis improving the patient’s level of function, well being and quality of life.

Maintenance care related to acupuncture refers to regularly scheduled treatments for an indefinite period of time after signs and/or symptoms have been relieved or have reached a plateau. The intention of maintenance care is to prevent the condition from getting worse.

Restorative therapy related to acupuncture is treatment of signs or symptoms that have returned or become more severe after having been previously relieved by acupuncture treatment. The purpose of restorative treatment is to restore the therapeutic gains previously achieved.

New condition is one that is different from the conditions treated with acupuncture during the current year.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

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; 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)

Diagnosis (ICD-10-CM) codes appropriate to acupuncture coverage

This code list is not all-inclusive but the following are covered:

Codes

Description

A18.01

Tuberculosis of spine

E89.41

Symptomatic postprocedural ovarian failure

F45.41

Pain disorder exclusively related to psychological factors

G43.001-G43.919

Migraine

G44.001-G44.59

Other headache syndromes

G50.0

Trigeminal neuralgia

G89.0-G89.4

Pain, not elsewhere classified

G93.3

Post viral fatigue syndrome

H93.11-H93.19

Tinnitus

I73.81

Erythromelalgia

M00.90

Pyogenic arthritis, unspecified

M05.40-M05.59, M05.70-M06.09, M06.20-M06.39, M06.80-M06.9

Rheumatoid arthritis

M06.4

Inflammatory polyarthropathy

M07.60-M07.69

Enteropathic arthropathies

M08.1

Juvenile ankylosing spondylitis

M12.10-M12.19

Kaschin-Beck disease

M12.50-M12.59

Traumatic arthropathy

M12.80-M12.9

Other specific arthropathies, not elsewhere classified

M13.0

Polyarthritis, unspecified

M13.10-M13.179

Monoarthritis, not elsewhere classified

M13.80-M13.89

Other specified arthritis

M15.0-M19.93

Osteoarthritis

M25.50-M25.579

Pain in joint

M25.70-M25.776

Osteophyte

M26.601-M26.69

Temporomandibular joint disorders

M43.20-M43.28

Fusion of spine

M43.8X8

Other specified deforming dorsopathies, sacral and sacrococcygeal region

M43.8X9

Other specified deforming dorsopathies, site unspecified

M45.0-M46.1

Ankylosing spondylitis & other inflammatory spondylopathies

M46.50-M46.99

Other and unspecified infective and inflammatory spondylopathies

M47.011-M48.38

Spondylosis & other spondylopathies

M48.50A-M48.9

Spondylosis & other spondylopathies

M49.80-M49.89

Spondylopathy in diseases classified elsewhere

M50.10-M50.13, M54.11-M54.13

Cervical radiculitis

M50.20-M50.23

Other cervical disc displacement

M50.90-M50.93

Cervical disc disorder, unspecified

M51.24-M51.27

Other thoracic, thoracolumbar and lumbosacral intervertebral disc displacement

M51.9

Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder

M51.14-M51.17

Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders with radiculopathy

M53.2X1-M53.9

Spinal instabilities and other specified dorsopathies

M54.10-M54.18

Radiculopathy

M54.2

Cervicalgia

M54.30-M54.32

Sciatica

M54.40-M54.5

Lumbago

M54.6

Pain in thoracic spine

M54.8-M54.9

Other & unspecified dorsalgia

M62.830

Muscle spasm of back

M72.9

Fasciitis

M75.00-M75.92

Shoulder lesions

M76.00-M76.9

Enthesopathies, lower limb, excluding foot

M77.00-M77.9

Other enthesopathies

M79.1-M79.2

Myalgia & Neuralgia and neuritis, unspecified

M79.601-M79.676

Pain in limb, hand, foot, fingers and toes

M79.7

Fibromyalgia

M99.22-M99.29

Subluxation stenosis of neural canal of thoracic and lumbar regions

M99.32-M99.39

Osseous stenosis of neural canal of thoracic and lumbar regions

M99.42-M99.49

Connective tissue stenosis of neural canal of thoracic and lumbar regions

M99.52-M99.59

Intervertebral disc stenosis of neural canal of thoracic and lumbar regions

M99.62-M99.69

Osseous and subluxation stenosis of intervertebral foramina of thoracic and lumbar regions

M99.72-M99.79

Connective tissue and disc stenosis of intervertebral foramina of thoracic and lumbar regions

N30.10-N30-11

Interstitial cystitis (chronic)

N64.4

Mastodynia

N91.0-N92.6, N93.8-N94.6, N95.0-N95.9

Menstrual disorders

O21.0-O21.9

Excessive vomiting in pregnancy

R11.2

Nausea with vomiting, unspecified

R51

Headache

R52

Pain, unspecified

R53.0

Neoplastic (malignant) fatigue

R53.1

Weakness

R53.81

Other malaise

R53.82

Chronic fatigue, unspecified

R53.83

Other fatigue

ICD-10-PCS Codes

Codes

Description

8E0H300

Acupuncture using Anesthesia

8E0H30Z

Acupuncture

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Cheong YC, Dix S, Hung Yu Ng E, Ledger WL, Farquhar C.. Acupuncture and assisted reproductive technology. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD006920. DOI: 10.1002/14651858.CD006920.pub3.
  2. ECRI Institute. (2014). Hotline Response. Acustimulation Therapy for Treating Nausea and Vomiting. Plymouth Meeting, PA: ECRI Institute.
  3. Hayes, Inc. Hayes directory: Acupuncture for assisted reproduction. Lansdale, PA: Hayes, Inc. July 2011. Reviewed June 2015. Archived August 2016
  4. Hayes, Inc. Hayes directory: Acupuncture for treatment of addictive behavior. Lansdale, PA: Hayes, Inc. May 2015. Reviewed May 2009. Archived June 2010.
  5. Hayes, Inc. Hayes directory: Acupuncture for treatment of low back pain. Lansdale, PA: Hayes, Inc. October 2010. Reviewed September 2014. Archived November 2015.
  6. Hayes, Inc. Hayes directory: Acupuncture for treatment of headache. Lansdale, PA: Hayes, Inc. May 2009. Reviewed February 2013. Archived June 2014.
  7. Hayes, Inc. Hayes directory: Acupuncture and Acupressure for the Treatment of Nausea and Vomiting. Lansdale, PA: Hayes, Inc June 2010. Reviewed May 2014. Archived July 2015.
  8. Hayes, Inc. Hayes Health Technology Brief. Acupuncture for treatment of chronic obstructive pulmonary disease (COPD). Lansdale, PA: Hayes, Inc.; August, 2013. Reviewed June 2015. Archived September 2016.
  9. Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Vertosick EA, Vickers A, White AR. Acupuncture for the prevention of episodic migraine (Review). Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD001218. DOI: 10.1002/14651858.CD001218.pub3.
  10. Witt CM, Reinhold T, Brinkhaus B, et al. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol 2008;198:166.e1-166.e8.

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Policy activity

  • 10/31/1994 - Date of origin
  • 11/01/2016 - Effective date
Review date
  • 10/2017
Revision date
  • 11/14/2016

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