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|2022 POLICY LAST REVIEWED: 11|05|2025

OVERVIEW This policy is applicable to all Commercial plans in which acupuncture services are a covered benefit.

For Commercial Products, Acupuncture services are not available as a standard benefit, but are available as mandated by Rhode Island General Law (RIGL) 27-20-42 (see full text below). This policy is written to reflect the coverage as it applies to Commercial groups that purchase a plan with acupuncture services.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION Not applicable

POLICY STATEMENT Commercial Products Acupuncture and an initial evaluation (for a new patient) is covered when rendered by a licensed doctor of acupuncture (D. Ac.) or physician (State of Rhode Island-licensed MD or DO)* only. Acupuncture assistants are not recognized for separate reimbursement and are therefore considered inclusive of the acupuncture reimbursement.

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.

The following services are not covered: • Αcupuncture with electrical stimulation for any indication unrelated to lower back pain; • Αdjunctive therapies, such as but not limited to moxibustion, herbs, oriental massage, etc.; • Αcupuncture when used as an anesthetic during a surgical procedure; • Precious metal needles (e.g., gold, silver, etc.); • Αcupuncture in lieu of anesthesia; • Αny other service not specifically listed as a covered service.

*Acupuncture services may be rendered by a physician (MD or DO) when the following Rhode Island Department of Health criteria has been met: 2.2 Any physician licensed in Rhode Island under the provisions of Chapter 5-37 who seeks to practice medical acupuncture as a therapy shall comply with the following:
2.2.1 Meet the requirements for licensure as a doctor of acupuncture set forth in the Rules and Regulations for Licensing Doctors of Acupuncture and Acupuncture Assistants promulgated by the Department of Health; or
2.2.2 Successfully complete a course offered to physicians that meets the requirements set forth in these regulations and includes no less than the following:
a) a minimum of three hundred (300) hours of formal instruction;
b) a supervised clinical practicum incorporated into the formal instruction required in subsection 2.2.2(a) (above). Payment Policy | Acupuncture Services for Commercial Products

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

COVERAGE Commercial Products Acupuncture is a covered benefit for those groups who have purchased a plan with an acupuncture benefit. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable acupuncture benefits/coverage.

BACKGROUND Acupuncture is the practice of piercing the skin with needles at specific body sites to induce anesthesia, to relieve pain, to treat various nonpainful disorders, and to alleviate withdrawal symptoms of opioid dependence. Acupuncture has also been used or proposed for a large variety of indications.

Acupuncture is a traditional form of Chinese medical treatment that has been practiced for over 2000 years. It involves piercing the skin with needles at specific body sites. The placement of needles into the skin is dictated by the location of meridians. These meridians, or channels, are thought to mark patterns of energy, called Qi (Chi), which flow through the human body. According to traditional Chinese philosophy, illness occurs when the energy flow is blocked or unbalanced, and acupuncture is a way to influence chi and restore balance. Another tenet of this philosophy is that all disorders are associated with specific points on the body, on or below the skin surface.

Several physiologic explanations of acupuncture’s mechanism of action have been proposed including an analgesic effect from release of endorphins or hormones (eg, cortisol, oxytocin), a biomechanical effect, and/or an electromagnetic effect.

There are 361 classical acupuncture points located along 14 meridians, and different points are stimulated depending on the condition treated. In addition to traditional Chinese acupuncture, there are a number of modern styles of acupuncture, including Korean and Japanese acupuncture. Modern acupuncture techniques can involve stimulation of additional non-meridian acupuncture points. Acupuncture is sometimes used along with manual pressure, heat (moxibustion), or electrical stimulation (electroacupuncture). Acupuncture treatment can vary by style and by practitioner, and is generally personalized to the patient. Thus, patients with the same condition may receive stimulation of different acupuncture points.

Scientific study of acupuncture is challenging due to the multifactorial nature of the intervention, variability in practice, and individualization of treatment. There has been much discussion in the literature on the ideal control condition for studying acupuncture. Ideally, the control condition should be able to help distinguish between specific effects of the treatment and nonspecific placebo effects related to factors such as patient expectations and beliefs and the patient-provider therapeutic relationships. A complicating factor in selection of a control treatment is that it is not clear whether all 4 components (ie, the acupuncture needles, the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle) are necessary for efficacy.

§ 27-20-42 Acupuncture services. – (a) Every group health insurance contract, plan, or group policy delivered, issued for delivery or renewed in this state which provides medical coverage, and every group policy which provides for treatment of persons for the prevention, cure or correction of any illness or physical or mental condition shall provide, as an optional rider, coverage for the services of a doctor of acupuncture as a provider of acupuncture services.
(b) For the purposes of this section:
(1) "Doctor of acupuncture" means a practitioner licensed under chapter 37.2 of title 5.
(2) "Coverage for the services of a doctor of acupuncture as a provider of acupuncture services" means coverage for acupuncture as defined in § 5-37.2-2(1).
(c) It remains within the sole discretion of the non-profit medical service corporation as to which doctor of acupuncture it contracts with. Reimbursement is provided according to the respective principles and policies of the non-profit medical service corporation; provided, that no non-profit medical service corporation may be required to pay for duplicative services actually

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

rendered by a doctor of acupuncture and any other health care provider. Nothing contained in this section precludes non-profit medical service corporations from conducting managed care, medical necessity or utilization review.

Note: Rhode Island-mandated benefits do not apply to Plan 65, FEHBP, and Medicare Advantage plans. Self-funded groups may or may not choose to follow state mandate(s).

CODING Commercial Products Local providers in the Acupuncture Specialty (053) are able to file only the codes found in this policy.

Providers should not file an E & M service on the same date of service as the acupuncture service unless it meets the definition for use of Modifier -25. The acupuncture codes and services 97810, 97811, 97813, 97814 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.

The following CPT codes are covered when a plan with acupuncture services has been purchased: 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)

The following CPT codes are covered for calendar year 2022 (effective date as per individual or group plan renewal) when a plan with acupuncture services has been purchased, when filed with a covered diagnosis: 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)

Low Back Pain Covered Diagnoses

Evaluation and Management codes are only used for separately identifiable procedures.
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires a

medically appropriate history and/or examination and straightforward medical decision making.

When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires a

medically appropriate history and/or examination and low level of medical decision making. When

using time for code selection, 30-44 minutes of total time is spent on the date of the encounter 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires a

medically appropriate history and/or examination and moderate level of medical decision making.

When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires a

medically appropriate history and/or examination and high level of medical decision making. When

using time for code selection, 60-74 minutes of total time is spent on the date of the encounter 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 (Revised text
1/01/2022) 99212 Office or other outpatient visit for the evaluation and management of an established patient, which

requires a medically appropriate history and/or examination and straightforward medical decision

making. When using time for code selection, 10-19 minutes of total time is spent on the date of the

encounter 99213 Office or other outpatient visit for the evaluation and management of an established patient, which

requires a medically appropriate history and/or examination and low level of medical decision

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

making. When using time for code selection, 20-29 minutes of total time is spent on the date of the

encounter 99214 Office or other outpatient visit for the evaluation and management of an established patient, which

requires a medically appropriate history and/or examination and moderate level of medical decision

making. When using time for code selection, 30-39 minutes of total time is spent on the date of the

encounter 99215 Office or other outpatient visit for the evaluation and management of an established patient, which

requires a medically appropriate history and/or examination and high level of medical decision

making. When using time for code selection, 40-54 minutes of total time is spent on the date of the

encounter

RELATED POLICIES Acupuncture for Medicare Advantage Plans

PUBLISHED Provider Update, November 2025 Provider Update, March 2025 Provider Update, December 2021 Provider Update, December 2020 Provider Update, December 2019 Provider Update, May 2019 Provider Update, April 2018

REFERENCES

1. RIGL Mandate 27-20-42, http://webserver.rilin.state.ri.us/Statutes/TITLE27/27-20/27-20-42.HTM
2. http://www.acupuncturetoday.com/mpacms/at/article.php?id=32315
3. http://www.acupuncturetoday.com/mpacms/at/article.php?id=30032
4. World Health Organization (WHO). A Proposed Standard International Acupuncture Nomenclature: Report of a WHO Scientific Group. 1991; http://apps.who.int/medicinedocs/en/d/Jh2947e/4.3.html. Accessed October 18, 2016.
5. Food and Drug Administration. Complementary and Alternative Medicine Products and their Regulation by the Food and Drug Administration. http://www.fda.gov/RegulatoryInformation/Guidances/ucm144657.htm#f11. Accessed October 26, 2016.
6. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. Jun 28 2016(6):CD001218. PMID 27351677
7. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. Apr 19 2016;4:CD007587. PMID 27092807
8. Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev. Jan 25 2005(1):CD001351. PMID 15674876
9. Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Cochrane Database Syst Rev. Apr 18 2005(2):CD005319. PMID 15846753
10. Green S, Buchbinder R, Barnsley L, et al. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev. 2002(1):CD003527. PMID 11869671
11. O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003(1):CD003219. PMID 12535461
12. Paley CA, Johnson MI, Tashani OA, et al. Acupuncture for cancer pain in adults. Cochrane Database Syst Rev. Oct 15 2015(10):CD007753. PMID 26468973
13. Boldt I, Eriks-Hoogland I, Brinkhof MW, et al. Non-pharmacological interventions for chronic pain in people with spinal cord injury. Cochrane Database Syst Rev. Nov 28 2014(11):CD009177. PMID 25432061

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

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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

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 6 (401) 274-4848 WWW.BCBSRI.COM

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.