Cigna / ASH Medical Coverage Policies

Cigna / ASH Medical Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document may differ significantly from the standard benefit plans upon which these Cigna / ASH Medical Coverage Policies are based. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Cigna / ASH Medical Coverage Policy. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.

Determinations in each specific instance may require consideration of:

1. the terms of the applicable benefit plan document in effect on the date of service
2. any applicable laws/regulations
3. any relevant collateral source materials including Cigna-ASH Medical Coverage Policies and
4. the specific facts of the particular situation

Cigna / ASH Medical Coverage Policies relate exclusively to the administration of health benefit plans. Cigna / ASH Medical Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. Some information in these Coverage Policies may not apply to all benefit plans administered by Cigna. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make benefit determinations. References to standard benefit plan language and benefit determinations do not apply to those clients.

Acupuncture is subject to the terms, conditions and limitations of the benefits as described in the applicable plan’s schedule of copayments. Please refer to the applicable benefit plan document to determine benefit availability and the terms and conditions of coverage.

GUIDELINES

ACUPUNCTURE

Medically Necessary
If coverage for acupuncture services are available in the applicable benefit plan document, acupuncture may be provided as treatment for ANY of the following conditions when ALL of the medical necessity factors and ALL of the treatment planning /outcomes listed below are met:

• Tension-type Headache; Migraine Headache with or without Aura
• Musculoskeletal joint and soft tissue pain (e.g., hip, knee, spine) resulting in a functional deficit (e.g., inability to perform household chores, interference with job functions, loss of range of motion)
• Nausea Associated with Pregnancy (only when co-managed)
• Post-Surgical Nausea (only when co-managed)
• Nausea Associated with Chemotherapy; (only when co-managed)

Acupuncture (CPG 024)

Medical Necessity Factors:
Medically necessary services must be delivered toward defined reasonable and evidence-based goals;
• Medical necessity decisions must be based on patient presentation including diagnosis, severity, and documented clinical findings;
Continuation of treatment is contingent upon progression towards defined treatment goals and evidenced by specific significant objective functional improvements (e.g., outcome assessment scales, range of motion)
Certain conditions require that the patient is being co-managed by a medical physician in order to be considered medically necessary;
Medically necessary services including monitoring of outcomes and progress with a change in treatment or withdrawal of treatment if the patient is not improving or is regressing.

Treatment Planning/Outcome Factors:

An individualized treatment plan (e.g., frequency and duration of service) is appropriately correlated with clinical findings and clinical evidence;

Treatment is expected to result in significant therapeutic improvement over a clearly defined period of time;

Therapeutic goals are functionally oriented, realistic, measurable, and evidence-based; • Proposed date of release/discharge from treatment is estimated; • Functional Outcome Measures (FOM)*, when used, demonstrates Minimal Clinically Important Difference (MCID) from baseline results through periodic re-assessments;

Documentation substantiates practitioner’s diagnosis and treatment plan; • Demonstration of progression toward active home/self-care and discharge, and; • Maximum therapeutic benefit has not been reached. Not all outcome measures have MCID’s determined and supported in the literature. Actual significance of these findings requires correlation with the overall clinical presentation, including updated subjective and objective examination findings

Not Medically Necessary

Acupuncture is considered not medically necessary for any of the following indications:

• Treatment intended to improve or maintain general physical condition
• Maintenance acupuncture services, when significant therapeutic improvement is not expected
• Services that do not require the skills of a qualified provider of acupuncture including but not limited to:
  • Activities and services that can be practiced independently and can be self-administered safely and effectively.
  • Home exercise programs that can be performed safely and independently to continue therapy without skilled supervision.
• Experimental, Investigational, Unproven
  Acupuncture for any other indication, including infertility and recurrent pregnancy loss, is considered experimental, investigational or unproven.

ACUPUNCTURE POINT INJECTION THERAPY

Acupuncture point injection therapy is considered experimental, investigational or unproven.

DESCRIPTION AND BACKGROUND

Acupuncture (CPG 024)

Acupuncture is a form of complementary and alternative medicine that has been widely practiced for many centuries. It involves the stimulation of specific anatomical locations on the skin through the penetration of fine needles, with the goal of relieving pain or treating disease. Stimulation can be accomplished manually (i.e., by a twisting motion of the hand) or through such methods as electrical stimulation (i.e., electroacupuncture). The practice of traditional acupuncture is predicated upon several fundamental underlying principles. It is predicated upon the existence of a series of meridians that course through the body along which are located discrete points that correspond to specific organs and/or have particular clinical significance. A vital energy, “chi,” flows through the meridians and the acupuncture points and regulating bodily functions. It is the disruption of this flow of energy that therapeutic acupuncture is said to address. Acupuncture typically utilizes unique diagnostic procedures to evaluate the meridian/chi system. This includes an evaluation of the patient’s chief complaint and related health status through standardized diagnostic interviewing and examination techniques. Interviews are based on the traditional Ten Questions and examinations include, but are not limited to, evaluation of meridians, points, general vitality and behavior, the radial pulses and the tongue. Based upon the patient’s complaint and the findings of these diagnostic procedures, individualized treatment regimens are developed that specify treatment variables such as the acupuncture points to be utilized, needle placement, and type of needle stimulation.

A majority of states provide licensure or registration for acupuncture practitioners, although the scope of practice allowed under state requirements varies. Depending upon the jurisdiction, those licensed to administer acupuncture may include licensed acupuncturists (LAc), medical/osteopathic physicians (MD/DO), chiropractors (DC), naturopaths (ND), oriental medicine doctors (OMD), podiatrists (DPM), dentists (DDS/DMD), nurse practitioners (NP), physician assistants (PA), as well as other designated health care providers.

Depending upon the practitioner’s training, different systems of acupuncture diagnosis and treatment may be used. The National Institutes of Health (NIH) Consensus Panel and the U.S. Food and Drug Administration (FDA) consider acupuncture safe when performed by qualified practitioners using sterile needles. The FDA requires that sterile, nontoxic needles be used and that they be labeled for single use by qualified practitioners.

Acupuncture appears to be a relatively safe treatment with rare serious adverse side effects when performed by qualified practitioners who consistently adhere to the recommendations of the FDA regarding the use of sterile needles. Depending on the pain condition being treated, a course of acupuncture may last several weeks.

Although there is no consensus in the scientific literature regarding the optimal number of acupuncture treatments to administer or the duration of treatment for any condition, in general, there should be a reasonable expectation for clinical improvement. If no improvement is documented after an initial trial of two-four weeks treatment, an alternative treatment plan should be considered. If lack of clinical improvement continues following subsequent treatments re-evaluation by the referring provider may be indicated.

If measurable objective improvement is made, then progress towards identified goals should be clearly documented and the treatment plan updated accordingly. The necessity of continued care beyond a therapeutic trial is dependent upon objective evidence of improvement (i.e., functional gain).

Multiple different biological mechanisms have been proposed and studied to explain acupuncture. All of these proposed mechanisms are centrally mediated and not merely local physiologic responses. Most commonly it is thought that the stimulation of the acupuncture needle triggers the release of endogenous opioids (endorphins). This effect seems the most pronounced in electro-acupuncture.

Another possible mechanism is through the diffuse noxious inhibitory control pathway (DNIC). According to DNIC, a noxious stimulus applied to any region of the body can induce immediate suppression of pain transmission in neurons of the trigeminal caudalis and/or the spinal dorsal horn.

Another theory proposes that the descending serotoninergic inhibitory pathway is key to acupuncture analgesia. In addition, there is some preliminary evidence that acupuncture may have effects on the inflammatory response mediated through the autonomic nervous system.

Current available evidence indicates that insertion of acupuncture needles has an effect above waiting list controls but there is limited available evidence to define whether exact needle placement on established “Traditional” Acupuncture points is necessary to produce a result. None of the mechanisms of action postulated for acupuncture affects are sufficiently well understood to have established a dispositive answer to describe the exact physiological mechanism by which acupuncture produces its analgesic and antiemetic effects.

Acupuncture (CPG 024)

Acupuncture Point Injection Therapy:

Acupuncture point injection therapy is a procedure where pharmaceuticals and natural biologic products such as vitamins, herbal extracts and other homeopathics, are injected into the body at acupuncture points to prevent or treat disease. One solution in particular, isotonic saline, when injected theoretically allows activation of the acupuncture point for a longer period of time enhancing the therapeutic effect.

DOCUMENTATION GUIDELINES

Evaluation:

An initial evaluation service is essential to determine whether any acupuncture services are medically necessary, to gather baseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation service must include:

• An appropriate level of clinical history, examination, and medical decision-making relevant and appropriate to the individual’s complaint(s) and presentation;
• Subjective historical evaluation based on standardize method such as the 10 questions;
• Specific standardized and non-standardized tests, assessments, and tools;
• Interpretation and synthesis of all relevant clinical findings derived from history and physical examination for the purpose of clinical decision-making;
• Subjective and objective measurable, description of functional status using comparable and consistent methods;
• Summary of clinical reasoning and consideration of contextual factors with recommendations;
• The establishment of a working diagnosis;
• Plan of care with specific treatment techniques or activities to be used in treatment sessions that should be updated as the individual's condition changes;
• Frequency and duration of treatment (treatment dose);
• Functional, measurable, and time-framed long-term and short-term goals based on appropriate and relevant evaluation data; and
• Prognosis and discharge plan.

Treatment Sessions:

Acupuncture treatment can vary from Acupuncture alone (CPT codes 97810, 97811, 97813, 97814) to the use of a variety of modalities and procedures depending on the patient’s condition, response to care, and treatment tolerance. All services must be supported in the treatment plan and be based on an individual’s clinical condition. An acupuncture treatment session may include:

• A brief evaluation of the patient’s progress and response to previous treatment(s);
• Acupuncture with or without electric stimulation
• Related passive modalities (e.g.

indirect moxibustion, hot/cold packs
• Functional education in self-care and home management
• Reassessment of the individual's condition, diagnosis, plan, and goals as part of the treatment session
• Coordination, communication, and documentation
• Reevaluation, if there is a significant change in the individual's condition or there is a need to update and modify the treatment plan
Documentation of treatment sessions should include at a minimum:
Date of treatment
• Specific treatment(s) provided that match the procedure codes billed
• Total treatment time
• The individual's response to treatment
• Skilled ongoing reassessment of the individual's progress toward the goals
• Any progress toward the goals in objective, measurable terms using consistent and comparable methods

Any barriers to expected progress or changes to the plan of care
• Name and credentials of the treating clinician

Acupuncture (CPG 024)

Measuring Progress in Acupuncture:

Monitoring for clinically significant changes in historical/examination findings and functional status including, but not limited to:
Pain level per VAS 1-10 scale and Frequency of symptoms
• Reported interference with daily functional activities
• Validated Functional Outcome Measures specific for condition (Clinically significant therapeutic progress (MCID), improvement in pain, impairments and objective evaluation findings)

Length of time of relief after treatment rendered
• Monitoring for significant changes in reported patient medication or other resource utilization
• Tenderness on palpation
• Range of motion
• Observation (e.g. behavior, mobility, appearance of affected area)
• Barriers to expected progress (e.g.: co-morbid conditions, extremes of age, socio-economic factors)

Acupuncture Treatment Service:

The Acupuncture service includes a brief assessment of the patient’s condition, as well as documentation of the patient’s response to the treatment. A reevaluation (an Established Patient E/M service) is indicated when services above and beyond the usual pre-service and post-service work associated with the acupuncture services is required. This may include circumstances where there are new clinical findings, a rapid change in the individual's status, or failure to respond to treatment interventions. The E/M services may include all or some of the components of the initial evaluation, such as:
Data collection with objective measurements taken based on appropriate and relevant assessment tests and tools using comparable and consistent methods;

Clinical decision-making as to whether acupuncture care is still indicated;
• Organizing the composite of current health conditions and deciding a priority/focus of treatment;
• Modification of intervention(s);
• Revision in plan of care if needed;
• Evaluation of any meaningful changes in function;
• Deciphering effectiveness of intervention(s); and
• Updating the discharge plan as appropriate.
Identifying the appropriate intervention(s) for new or ongoing goal achievement;

Standardized Tests and Measures/Functional Outcome Measures (FOMs):

Measuring outcomes is an important component of an acupuncturist’s practice. Outcome measures are important in direct management of individual patient care and for the opportunity they provide the profession in collectively comparing care and determining effectiveness. The use of standardized tests and measures early in an episode of care establishes the baseline status of the patient, providing a means to quantify change in the patient's functioning. Outcome measures, along with other standardized tests and measures used throughout the episode of care provide information about whether predicted outcomes are being realized.

As the patient reaches the termination of acupuncture services and the end of the episode of care, the acupuncturist, again, measures the outcomes of their services. Standardized outcome measures provide a common language with which to evaluate the success of interventions, thereby providing a basis for comparing outcomes related to different intervention approaches. Measuring outcomes of care within the relevant components of function (including body functions and structures), activity, and participation, among patients with the same diagnosis, is the foundation for determining which intervention approaches comprise best clinical practice.