Clinical Policy: Acupuncture

Reference Number: CP.MP.92
Date of Last Revision: 06/24

[Coding Implications](Coding Implications)
[Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

Description

Acupuncture involves the manual and/or electrical stimulation of thin, solid, metallic needles inserted into the skin.¹ Acupuncture has been studied for the treatment of many conditions, but some of the more common and studied indications include pain and nausea and vomiting, hypertension, chronic obstructive pulmonary disease, allergic rhinitis and addictive behavior.

II. It is the policy of health plans affiliated with Centene Corporation that current evidence does not support the use of acupuncture for indications other than those listed above.

Background

Acupuncture is a form of complementary and alternative medicine (CAM) and one of the oldest medical procedures in the world.¹ It encompasses a large array of styles and techniques, however, the techniques most frequently used and studied are manual manipulation and/or electrical stimulation of thin, solid, metallic needles inserted into skin.¹

The typical acupuncture treatment begins with evaluation of the patient through inspection, auscultation, inquiring, and palpation. Once the evaluation is complete, treatment begins with fine metal needles being inserted into precisely defined points and remaining in place anywhere

Clinical Policy

Acupuncture

from five to 20 minuteswhile the patient lies relaxed.¹⁻² Treatments can occur one to two times a week, and the total number of sessions varies based on the patient’s condition, disease severity and chronicity.¹ There is insufficient evidence in studies to establish a defined treatment protocol for any condition.¹

There are many proposed models for the mechanism of action of the effects of acupuncture; however, the data have been either too inconsistent or inadequate to draw significant conclusions. The theory in regards to the analgesic effect of acupuncture, associates the neurotransmitter effects such as endorphin release at both the spinal and supraspinal levels. Functional magnetic resonance imaging (MRI) studies have demonstrated various physiologic effects, associating acupuncture points with changes in brain MRI signals. Another theory is that acupuncture points are associated with anatomic locations of loose connective tissue.¹

Evidence from a number of randomized, blinded, placebo-controlled studies indicate that acupoint stimulation can be effective in the management of postoperative nausea and vomiting, particularly in women, with mixed results in pediatric populations. Acupoint stimulation for women undergoing chemotherapy also reduced nausea and vomiting in some studies, but no effect was reported in a study involving both men and women. The evidence regarding alleviation of morning sickness by acupoint stimulation is limited, less rigorous than for postoperative nausea and vomiting, and ambiguous.³⁻⁴

Recent data on acupuncture for postoperative dental pain is limited, but earlier evidence indicated promising results for this use. Data was most promising for pain relief following tooth extraction.¹⁻²

There are a number of randomized controlled trials that establish improvement in headache frequency, intensity, response, use of relief medication and quality of life relative to usual care and relief treatment only. An updated Cochrane Review that previously noted promising, but insufficient evidence in support of acupuncture for migraine headache indicates, “there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care,” following the completion of 12 additional trials.⁵ However, according to Hayes, ambiguity remains due to the low quality of the evidence and the variety of the studies evaluated, considering the diversity in acupuncture technique, number of treatment sessions, and length of follow-up.⁶

Acupuncture for osteoarthritis pain appears to be effective, particularly for pain in the knee. Recent literature has shown relief of pain and improved function in osteoarthritis of the knee for patients treated with acupuncture.¹⁻⁷ According to the American College of Rheumatology/Arthritis Foundation, acupuncture is conditionally recommended for osteoarthritis in the knee, hip, or hand, but the most positive trials with the greatest effect were in relation to knee osteoarthritis.⁸

Acupuncture has been studied for a variety of other reasons, but studies and evidence does not currently support its use for indications such as, but not limited to, arm pain, temporomandibular joint dysfunction, menstrual cramps and fibromyalgia.¹⁻⁹

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Acupuncture

Coding Implications

This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

2. Health Technology Assessment. Acupuncture for treatment of postoperative pain: a review of reviews. Hayes. www.hayesinc.com. Published May 25, 2018 (annual review May 11, 2022). Accessed May 30, 2024.
3. Health Technology Assessment. Acupuncture for the prevention or treatment of nausea and vomiting: A review of reviews. Hayes. www.hayesinc.com. Published September 19, 2018 (annual review September 28, 2022). Accessed May 30, 2024.
4. Kemper KJ. Complementary and integrative health in pediatrics. UpToDate. www.uptodate.com. Updated November 09, 2022. Accessed May 30, 2024.
5. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016;2016(6):CD001218. Published 2016 Jun 28. doi:10.1002/14651858.CD001218.pub3
6. Health Technology Assessment. Comparative effectiveness review of acupuncture for the treatment of episodic and chronic tension headache and episodic migraine: a review of the reviews. Hayes. www.hayesinc.com. Published September 10, 2018 (annual review September 21, 2022). Accessed May 30, 2024.
7. Kelly RB, Willis J. Acupuncture for Pain. Am Fam Physician. 2019;100(2):89 to 96.
8. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee (published correction appears in Arthritis Rheumatol. 2021 May;73(5):799). Arthritis Rheumatol. 2020;72(2):220-233. doi:10.1002/art.41142
9. Health Technology Assessment. Acupuncture for treatment of fibromyalgia. Hayes. www.hayesinc.com. Published August 28, 2018 (annual review August 19, 2022). Accessed May 30, 2024.
10. American Society of Anesthesiologists Task Force on Chronic Pain Management; American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112(4):810 to 833. doi:10.1097/ALN.0b013e3181c43103
11. MacPherson H, Tilbrook H, Richmond S, et al. Alexander Technique lessons or Acupuncture Sessions for Persons With Chronic Neck Pain: A Randomized Trial (published correction appears in Ann Intern Med. 2016 Feb 2;164(3):204). Ann Intern Med. 2015;163(9):653 to 662. doi:10.7326/M15-0667
12. National Center for Complementary and Integrative Health. Acupuncture: What you need to know. https://www.nccih.nih.gov/health/acupuncture-in-depth. Updated October 2022. Accessed May 30, 2024.

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13. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444 to 1453. doi:10.1001/archinternmed.2012.3654
14. Aukerman G, Knutson D, Miser WF; Department of Family Medicine, Ohio State University College of Medicine and Public Health, Columbus, Ohio. Management of the acute migraine headache. Am Fam Physician. 2002;66(11):2123 to 2130.
15. ACOG Practice Bulletin. Number 189, Nausea and Vomiting of Pregnancy. American College of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/01/nausea-and-vomiting-of-pregnancy. Published January 2018. (Reaffirmed 2021). Accessed May 30, 2024.
16. Health Technology Assessment. Acupuncture for treatment of shoulder pain or chronic neck pain: A review of reviews. Hayes. www.hayesinc.com. Published August 22, 2018 (annual review August 18, 2022). Accessed May 30, 2024.
17. National coverage determination: acupuncture (30.3). Centers for Medicare and Medicaid Services Web site. www.cms.gov/medicare-coverage-database/search.aspx. Published January 21, 2020. Accessed May 30, 2024.
18. Smith JA, Fox KA, Clark SM. Nausea and vomiting of pregnancy: Treatment and outcome. UpToDate. www.uptodate.com. Updated July 14, 2023. Accessed May 30, 2024.
19. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1 to 211. doi:10.1177/033312217738202
20. O’Brien H. Types of migraine and related syndromes in children. UpToDate. www.uptodate.com. Updated January 3, 2024. Accessed May 30, 2024.

Important Reminder

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as state and federal requirements and applicable Health Plan-level administrative policies and procedures.

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Acupuncture

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

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