Anthem Blue Cross Connecticut CG-ANC-03 Acupuncture Form

This document addresses the use of acupuncture, the practice of stimulating specific points on the body using needles for the purpose of treating various health conditions. Manual manipulation or electrical stimulation of the needles may or may not be incorporated into therapy.

Note: For additional information regarding the use of auricular electroacupuncture, please see:

• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

Clinical Indications

Medically Necessary:

The use of acupuncture is considered medically necessary when one or more of the following conditions is the target of therapy:

1. Nausea or vomiting associated with surgery, chemotherapy, pregnancy; or
2. Chronic osteoarthritis of the knee or of the hip that is significantly affecting daily activity; or
3. Cancer pain; or
4. Tension headache recurring for more than 12 weeks despite medication or behavioral therapy (such as biofeedback or relaxation therapy); or
5. Migraine recurring for more than 12 weeks despite medication treatment; or
6. Back or neck pain persisting for more than 12 weeks despite medication and physical therapy.

Continuing treatment:

Continuing use of acupuncture therapy is considered medically necessary when both of the following are met (A and B):

1. The individual to be treated continues to experience one or more of the conditions listed above; and
2. The requesting physician documents ongoing benefit from the use of acupuncture.

Not Medically Necessary:

Acupuncture is considered not medically necessary when the criteria above are not met, and for any other indication.