Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 01|01|2021 POLICY LAST REVIEWED: 11|05|2025

OVERVIEW This policy provides an overview of acupuncture for chronic low back pain (cLBP) and dry needling benefit for Medicare Advantage Plans.
Effective January 1, 2026, all non-covered acupuncture services are no longer covered for individual Medicare Advantage plans (i.e. dry needling)

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION Not applicable

POLICY STATEMENT Medicare Advantage Plans Acupuncture and an initial evaluation (for a new patient) are covered when rendered by a licensed provider* for a covered indication.

*Licensed doctor of acupuncture (D. Ac.) or physician (MD or DO) may furnish acupuncture in accordance with applicable state requirements. Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have: • A master’s or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and,
• A current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e., Puerto Rico) of the United States or District of Columbia.

An initial evaluation (99202-99205) is allowed only for new patients.

Acupuncture for Chronic Low Back Pain Up to 20 acupuncture or dry needling visits are covered for chronic low back pain (cLBP). For this benefit per Centers for Medicare and Medicaid (CMS); chronic low back pain is defined as: • lasting 12 weeks or longer; nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); • not associated with surgery. • not associated with pregnancy.

Services greater than 20 treatments administered annually are not covered.

Acupuncture for all other indications are no longer covered for individual Medicare Advantage Plans effective January 1, 2026; this includes:

Dry Needling Dry Needling, for any condition other than chronic low back pain, is not covered.

In addition, the following services are not covered: Payment Policy | Acupuncture and Dry Needling Services Medicare Advantage Plans d

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

• adjunctive therapies, such as but not limited to moxibustion, herbs, oriental massage, etc.; • acupuncture when used as an anesthetic during a surgical procedure; • precious metal needles (e.g., gold, silver, etc.); • acupuncture in lieu of anesthesia; • any other service not specifically listed as a covered service.

COVERAGE Medicare Advantage Plans Acupuncture is a covered service for Medicare Advantage members/products only when the diagnosis is related to cLBP for individual Medicare Advantage plans. Please refer to the member’s Evidence of Coverage for applicable acupuncture benefits/coverage.

BACKGROUND Acupuncture is the selection and manipulation of specific acupuncture points through the insertion of needles or “needling,” or other “non-needling” techniques focused on these points. There are several variations to traditional acupuncture including shallow needling, intradermal needling, or intramuscular needling with or without a sensation of numbness, tingling, electrical sensation, fullness, distension, soreness, warmth or itching felt by a patient around an acupuncture point. Acupuncturists may additionally seek a sensation of tenseness or dragging to the needles obtained by twirling, plucking, or thrusting of acupuncture needles.

CODING Medicare Advantage Plans Local providers in the Acupuncture Specialty may submit acupuncture services for consideration that are found in this policy.

Chronic Low Back Pain The following CPT codes are covered according to the members’ benefit when filed with a covered diagnosis.
CPT Codes 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)

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)

For covered diagnoses, please refer to link below:

Low Back Pain covered diagnoses

All other indications other than Chronic Low Back Pain effective January 1, 2026, are no longer covered for members with individual Medicare Advantage plans.

Effective January 1, 2026, the following services are no longer covered for members with individual Medicare Advantage plans:

Dry Needling 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s)
20561 Needle insertion(s) without injection(s); 3 or more muscles

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Effective January 1, 2026, the following E&M services are no longer covered for members with individual Medicare Advantage plans:

Evaluation and Management Services The following codes are covered according to the members’ specialist benefit when filed according to guidelines in the policy statement:

Evaluation and Management CPT codes are only used for separate identifiable procedures.
99202 Office or other outpatient visit for the evaluation and management of a new patient 99203 Office or other outpatient visit for the evaluation and management of a new patient 99204 Office or other outpatient visit for the evaluation and management of a new patient 99205 Office or other outpatient visit for the evaluation and management of a new patient

Note: An initial evaluation (99202-99205) is allowed only for new patients. According to CPT guidelines, a new patient is one who has not received any professional services from the physician within the past three years.

99211 Office or other outpatient visit for the evaluation and management of an established patient, that may
not require the presence of a physician or other qualified health care professional 99212 Office or other outpatient visit for the evaluation and management of an established patient 99213 Office or other outpatient visit for the evaluation and management of an established patient 99214 Office or other outpatient visit for the evaluation and management of an established patient 99215 Office or other outpatient visit for the evaluation and management of an established patient

Note: An E&M service and the acupuncture service(s) CPT Codes 97810, 97811 when charged on the same day, the E&M is not covered. These acupuncture codes include pre-service, intra-service and post-service evaluation and management for the typical following factors of history, evaluation, management, and chart documentation done as part of the overall daily treatment.

Note: An E&M service and the acupuncture service(s) CPT Codes 97813, 97814 when charged on the same day, the E&M is covered providing the E&M service meets the definition for use of Modifier -25 (significant, separately identifiable E&M on the same day).

RELATED POLICIES None

PUBLISHED Provider Update November 2025 Provider Update December 2023 Provider Update August 2022 Provider Update December 2021 Provider Update December 2020

REFERENCES

1. CMS.GOV, Centers for Medicare & Medicaid Services: National Coverage Determination for Acupuncture (30.3)
2. CMS.GOV, Centers for Medicare & Medicaid Services: National Coverage Determination for Acupuncture for Chronic Low Back Pain (cLBP) (30.3.3).
3. CMS.GOV, Centers for Medicare & Medicaid Services: National Coverage Determination for Acupuncture for Fibromyalgia (30.3.1).
4. CMS.GOV, Centers for Medicare & Medicaid Services: National Coverage Determination for Acupuncture for Osteoarthritis (30.3.2)
5. CMS.GOV, MLN Matters Number 13288 - : National Coverage Determination for Acupuncture for Chronic Low Back Pain (cLBP) (30.3.3).

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

6. MM11755 - National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Lower Back Pain (cLBP)

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS