Coverage criteria policies

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.

Prior authorization is not required for Acupuncture.

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,myofascial 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.

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.

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

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

ICD-10-PCS Codes

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.

Approved Benefits and Medical Directors Committees 10/31/94; Revised 5/25/05, 12/14/06, 12/26/07, 4/1/09; 11/14/16; Annual Review 12/14/06, 8/1/07, 1/1/08, 4/1/09, 10/28/10, 10/2011, 10/2012, 10/2013, 10/2014, 10/2015, 10/2016, 10/2017, 9/2018

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:
3. ECRI Institute. (2017). Custom Rapid Responses – Guidance Acupuncture for Treating Chronic Pain. Plymouth Meeting, PA: ECRI Institute.
4. Hayes, Inc. Hayes directory: Acupuncture for assisted reproduction. Lansdale, PA: Hayes, Inc. July 2011. Reviewed June 2015. Archived August 2016
5. Hayes, Inc. Hayes technology directory report: Acupuncture for the Treatment of Chronic Lower back pain: A Review of Reviews. Lansdale, PA: Hayes, Inc., .June 2018
6. 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
7. .Hayes, Inc. Hayes Medical Technology Directory Report. Acupuncture for the Treatment of Knee Osteoarthritis: Review of Reviews, Lansdale, PA: Hayes Inc.,July 2018.
8. Hayes, Inc Hayes Medical Technology Directory Report. Acupuncture for Treatment of Fibromyalgia, August 2018
9. Hayes, Inc. Hayes Medical Technology Directory Report. Acupuncture for the Treatment of Episodic and Chronic Tension-Type Headache and Episodic Migraine: A Review of Reviews. Lansdale, PA: Hayes, Inc., Sept 2018.
10. September 2018. Hayes, Inc. Hayes Medical Technology Directory Report. Acupuncture for Treatment of Shoulder Pain or Neck Pain. Lansdale, PA: Hayes, Inc.; August, 2018.
11. Hayes, Inc. Hayes Medical Technology Directory Report. Acupuncture for Treatment of Postoperative Pain: A Review of Reviews. Lansdale, PA: Hayes, Inc.; May, 2018.
12. 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.
13. 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.
14. 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.