Prior authorization request form Form

Acupuncture
EmblemHealth Medicare HMO Plans with Acupuncture Benefit

Last Review Date: April 10, 2026 
Number: MG.MM.ME.70cC7

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. No prior authorization is required for the diagnoses approved services under this policy. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, (“EmblemHealth”) has adopted the herein policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc.

Definition Acupuncture is the practice of piercing the skin with needles at specific body sites to induce anesthesia, to relieve pain to alleviate withdrawal symptoms of substance abusers, or to treat various non-painful disorders. The placement of needles into the skin is dictated by the location of meridians. These meridians are thought to mark patterns of energy flow throughout the human body. Acupuncture has 4 components—the acupuncture needle(s), the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle. Acupuncture may be performed with or without electrical stimulation

Guideline Members of certain Medicare HMO plans are eligible for acupuncture when performed by an individual licensed by New York State to perform acupuncture and when performed for the following diagnoses:

1. Adult postoperative nausea and vomiting
2. Chemotherapy related nausea and vomiting
3. Pregnancy related nausea and vomiting
4. Carpal tunnel syndrome
5. Epicondylitis (tennis elbow)
6. Headache
7. Low back pain (not covered as of Jan. 21, 2020. See CMS National Coverage Determination Acupuncture for Chronic Low Back Pain (cLBP)
8. Menstrual pain
9. Myofascial pain
10. Osteoarthritis

Limitations/Exclusions

1. Acupuncture point injections (aka acupoint injection therapy or biopuncture) — a procedure by which pharmaceuticals and natural biologic products (i.e., vitamins, herbal extracts and other homeopathics) are injected into the body at acupuncture points for disease treatment/prevention — are considered investigational. Conditions regarded as investigational include the following (list not all-inclusive): a. Amyotrophic lateral sclerosis. b. Cancer-related pain c. Cervical spondylosis d. Chronic daily headache e. Dysmenorrhea (menstrual pain) f. Epicondylitis
2. Acupuncture is considered investigational for all indications other than those listed above; including the following (list not all-inclusive) Acne Addiction/substance abuse AIDS Allergies Amblyopia Asthma Attention deficit hyperactivity disorder (ADHD) Autism spectrum disorders Bell's palsy Breast cancer-related hot flashes Burning mouth syndrome Cancer-induced bone pain Cancer-related dyspnea Cancer-related fatigue Carpal tunnel syndrome Cerebral palsy Chemotherapy-induced leukopenia Chemotherapy-induced neuropathic pain Chronic pain syndrome (e.g., RSD, facial pain) Chronic obstructive pulmonary disease (COPD) Chronic constipation Chronic fatigue syndrome Cognitive impairment Diabetic gastroparesis Diabetic peripheral neuropathy Dry eyes Endometriosis pain Epilepsy Erectile dysfunction Facial spasm Fetal breech presentation Fibromyalgia Fibrotic contractures Glaucoma Heart failure Hypertension Hypoxic ischemic encephalopathy Induction of labor Infantile colic Infantile diarrhea
   Infertility (e.g., to assist oocyte retrieval and embryo transfer Intra-cerebral hemorrhage Irritable bowel syndrome Menopause-associated vasomotor symptoms Menopausal hot flashes Menstrual cramps/dysmenorrhea Multiple sclerosis Mumps Myopia Neck pain/cervical spondylosis Nocturnal enuresis Obesity/ weight reduction Painful neuropathies Parkinson's disease Parkinson's disease-related fatigue Peripheral arterial disease (e.g., intermittent claudication) Phantom leg pain Plantar fasciitis Polycystic ovary syndrome Post-herpetic neuralgia Post-operative ileus Post-traumatic stress disorder Pruritus Psoriasis Psychiatric disorders (e.g., anxiety, depression, and schizophrenia)
   Raynaud’s disease pain Recurrent pregnancy loss Respiratory disorders Rheumatoid arthritis Rhinitis Sensorineural deafness Smoking cessation Spasticity after stroke Stroke rehabilitation (e.g., dysphagia) Tension headache Tic disorders (e.g., Tourette syndrome) Tinnitus Urinary incontinence Uterine fibroids

during IVF treatment cycle) Inflammatory bowel diseases (Crohn's disease and ulcerative colitis) Insomnia (including cancer-related insomnia) Xerostomia Whiplash
Reimbursement
EmblemHealth will reimburse acupuncture services as follows eff. 11/9/2019:  Credentialed participating licensed acupuncturists or physicians (MD or DO) only  Acupuncture service CPT codes 97810–97814
 Acupuncture reimbursement is limited to a maximum of four total service units in any combination, per date of service, subject to correct coding  Either acupuncture or evaluation and management (E/M) on the same day, but not both:
o For acupuncture with a new patient E/M (including separately identifiable service- modifier 25), EmblemHealth will reimburse only the E/M service o For acupuncture with established patient E/M (including separately identifiable service- modifier 25), EmblemHealth will reimburse only the acupuncture service EmblemHealth will not reimburse acupuncture services as follows eff. 11/9/2019: • Codes other than those listed in the coding grid below. • Acupuncture students, interns, or fellows directly or under EmblemHealth Revision History Jun. 16, 2023 Substituted the link to EmblemHealth’s Acupuncture for Chronic Low Back Pain policy with a direct link to corresponding CMS National Coverage Determination
Mar. 13, 2020
Removed low back pain eff. 1/21/2020 (re-direct link provided to new policy specific to chronic low back pain)
Aug. 9, 2019 Title change to “EmblemHealth Medicare HMO Plans with Acupuncture Benefit
Added Reimbursement specifications eff. 11/9/2019 No clinical coverage revision
Mar. 8, 2019 Added coverage for VIP Premier for City of New York and VIP Rx Carve out City of New York plans (retroactive to Jan. 1, 2019) Removed shoulder pain from Limitations/Exclusions Jan. 1, 2019 Added coverage for Medicare VIP Essential members

Applicable Procedure Codes 97810 Acupuncture, 1 or more needles; with 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) (List separately in addition to code for primary procedure) 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) (List separately in addition to code for primary procedure)

Applicable Diagnosis Codes G43.001 Migraine without aura, not intractable, with status migrainosus G43.009 Migraine without aura, not intractable, without status migrainosus G43.011 Migraine without aura, intractable, with status migrainosus G43.019 Migraine without aura, intractable, without status migrainosus G43.101 Migraine with aura, not intractable, with status migrainosus G43.109 Migraine with aura, not intractable, without status migrainosus G43.111 Migraine with aura, intractable, with status migrainosus G43.119 Migraine with aura, intractable, without status migrainosus G43.401 Hemiplegic migraine, not intractable, with status migrainosus G43.409 Hemiplegic migraine, not intractable, without status migrainosus G43.411 Hemiplegic migraine, intractable, with status migrainosus G43.419 Hemiplegic migraine, intractable, without status migrainosus G43.501 Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus G43.509 Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus G43.511 Persistent migraine aura without cerebral infarction, intractable, with status migrainosus G43.519 Persistent migraine aura without cerebral infarction, intractable, without status migrainosus G43.601 Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus G43.609 Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus G43.611 Persistent migraine aura with cerebral infarction, intractable, with status migrainosus G43.619 Persistent migraine aura with cerebral infarction, intractable, without status migrainosus G43.701 Chronic migraine without aura, not intractable, with status migrainosus G43.709 Chronic migraine without aura, not intractable, without status migrainosus G43.711 Chronic migraine without aura, intractable, with status migrainosus G43.719 Chronic migraine without aura, intractable, without status migrainosus G43.801 Other migraine, not intractable, with status migrainosus G43.809 Other migraine, not intractable, without status migrainosus G43.811 Other migraine, intractable, with status migrainosus G43.819 Other migraine, intractable, without status migrainosus G43.821 Menstrual migraine, not intractable, with status migrainosus G43.829 Menstrual migraine, not intractable, without status migrainosus G43.831 Menstrual migraine, intractable, with status migrainosus G43.839 Menstrual migraine, intractable, without status migrainosus G43.901 Migraine, unspecified, not intractable, with status migrainosus G43.909 Migraine, unspecified, not intractable, without status migrainosus G43.911 Migraine, unspecified, intractable, with status migrainosus G43.919 Migraine, unspecified, intractable, without status migrainosus G43.B0 Ophthalmoplegic migraine, not intractable G43.C0 Periodic headache syndromes in child or adult, not intractable G43.D0 Abdominal migraine, not intractable G44.009 Cluster headache syndrome, unspecified, not intractable

G44.019 Episodic cluster headache, not intractable G44.1 Vascular headache, not elsewhere classified G44.209 Tension-type headache, unspecified, not intractable G44.219 Episodic tension-type headache, not intractable G44.229 Chronic tension-type headache, not intractable G44.309 Post-traumatic headache, unspecified, not intractable G44.319 Acute post-traumatic headache, not intractable G44.329 Chronic post-traumatic headache, not intractable G44.52 New daily persistent headache (NDPH)
G44.53 Primary thunderclap headache G44.59 Other complicated headache syndrome G44.81 Hypnic headache G44.83 Primary cough headache G44.84 Primary exertional headache G44.85 Primary stabbing headache G44.89 Other headache syndrome G89.0 Central pain syndrome G89.11 Acute pain due to trauma G89.12 Acute post-thoracotomy pain G89.18 Other acute postprocedural pain G89.21 Chronic pain due to trauma G89.22 Chronic post-thoracotomy pain G89.29 Other chronic pain G89.3 Neoplasm related pain (acute) (chronic) G89.4 Chronic pain syndrome K08.89 Other specified disorders of teeth and supporting structures [tooth pain] M16.0 Bilateral primary osteoarthritis of hip M16.10 Unilateral primary osteoarthritis, unspecified hip M16.11 Unilateral primary osteoarthritis, right hip M16.12 Unilateral primary osteoarthritis, left hip M16.2 Bilateral osteoarthritis resulting from hip dysplasia M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip M16.4 Bilateral post-traumatic osteoarthritis of hip M16.50 Unilateral post-traumatic osteoarthritis, unspecified hip M16.51 Unilateral post-traumatic osteoarthritis, right hip M16.52 Unilateral post-traumatic osteoarthritis, left hip M16.6 Other bilateral secondary osteoarthritis of hip M16.7 Other unilateral secondary osteoarthritis of hip M16.9 Osteoarthritis of hip, unspecified M17.0 Bilateral primary osteoarthritis of knee

M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.2 Bilateral post-traumatic osteoarthritis of knee M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee M17.31 Unilateral post-traumatic osteoarthritis, right knee M17.32 Unilateral post-traumatic osteoarthritis, left knee M17.4 Other bilateral secondary osteoarthritis of knee M17.5 Other unilateral secondary osteoarthritis of knee M17.9 Osteoarthritis of knee, unspecified M19.011 Primary osteoarthritis, right shoulder M19.012 Primary osteoarthritis, left shoulder M19.019 Primary osteoarthritis, unspecified shoulder M19.021 Primary osteoarthritis, right elbow M19.022 Primary osteoarthritis, left elbow M19.029 Primary osteoarthritis, unspecified elbow M19.031 Primary osteoarthritis, right wrist M19.032 Primary osteoarthritis, left wrist M19.039 Primary osteoarthritis, unspecified wrist M19.041 Primary osteoarthritis, right hand M19.042 Primary osteoarthritis, left hand M19.049 Primary osteoarthritis, unspecified hand M19.071 Primary osteoarthritis, right ankle and foot M19.072 Primary osteoarthritis, left ankle and foot M19.079 Primary osteoarthritis, unspecified ankle and foot M25.511 Pain in right shoulder M25.512 Pain in left shoulder M25.519 Pain in unspecified shoulder M25.521 Pain in right elbow M25.522 Pain in left elbow M25.529 Pain in unspecified elbow M25.531 Pain in right wrist M25.532 Pain in left wrist M25.539 Pain in unspecified wrist M25.551 Pain in right hip M25.552 Pain in left hip M25.559 Pain in unspecified hip M25.561 Pain in right knee M25.562 Pain in left knee M25.569 Pain in unspecified knee M25.571 Pain in right ankle and joints of right foot M25.572 Pain in left ankle and joints of left foot

M25.579 Pain in unspecified ankle and joints of unspecified foot M26.601 Right temporomandibular joint disorder, unspecified M26.602 Left temporomandibular joint disorder, unspecified M26.603 Bilateral temporomandibular joint disorder, unspecified M26.609 Unspecified temporomandibular joint disorder, unspecified side M26.611 Adhesions and ankylosis of right temporomandibular joint M26.612 Adhesions and ankylosis of left temporomandibular joint M26.613 Adhesions and ankylosis of bilateral temporomandibular joint M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side M26.621 Arthralgia of right temporomandibular joint
M26.622 Arthralgia of left temporomandibular joint M26.623 Arthralgia of bilateral temporomandibular joint M26.629 Arthralgia of temporomandibular joint, unspecified side M26.631 Articular disc disorder of right temporomandibular joint M26.632 Articular disc disorder of left temporomandibular joint M26.633 Articular disc disorder of bilateral temporomandibular joint M26.639 Articular disc disorder of temporomandibular joint, unspecified side M26.69 Other specified disorders of temporomandibular joint M53.0 Cervicocranial syndrome M53.1 Cervicobrachial syndrome M53.82 Other specified dorsopathies, cervical region M54.2 Cervicalgia M54.40 Lumbago with sciatica, unspecified side M54.41 Lumbago with sciatica, right side M54.42 Lumbago with sciatica, left side M54.6 Pain in thoracic spine M54.89 Other dorsalgia M60.9 Myositis, unspecified M62.40 Contracture of muscle, unspecified site M77.00 Medial epicondylitis, unspecified elbow M77.01 Medial epicondylitis, right elbow M77.02 Medial epicondylitis, left elbow M77.10 Lateral epicondylitis, unspecified elbow M77.11 Lateral epicondylitis, right elbow M77.12 Lateral epicondylitis, left elbow M79.1 Myalgia M79.601 Pain in right arm M79.602 Pain in left arm M79.603 Pain in arm, unspecified M79.604 Pain in right leg M79.605 Pain in left leg M79.606 Pain in leg, unspecified

M79.609 Pain in unspecified limb M79.641 Pain in right hand M79.642 Pain in left hand M79.643 Pain in unspecified hand M79.644 Pain in right finger(s) M79.645 Pain in left finger(s) M79.646 Pain in unspecified finger(s) O21.0 Mild hyperemesis gravidarum O21.1 Hyperemesis gravidarum with metabolic disturbance O21.2 Late vomiting of pregnancy O21.8 Other vomiting complicating pregnancy O21.9 Vomiting of pregnancy, unspecified R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.2 Nausea with vomiting, unspecified R51 Headache R68.84 Jaw pain T45.1X5A Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter T45.1X5D Adverse effect of antineoplastic and immunosuppressive drugs, subsequent encounter T45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs, sequela Z98.890 Other specified postprocedural states
References CMS. National Coverage Determination. Acupuncture. https://www.cms.gov/medicare-coverage- database/(S(cnbxfa45qfwykj45ydhic5qj))/details/ncd- details.aspx?NCDId=11&ncdver=1&NCAId=2&ver=5&NcaName=Acupuncture+for+Nausea+after+Chemotherapy+and+Post- operative+Pain&bc=AAAAABAAEAgA&. Accessed April 14, 2026. CMS. National Coverage Determination. Acupuncture for Fibromyalgia. https://www.cms.gov/medicare-coverage- database/details/ncd-details.aspx?NCDId=283&ncdver=1&bc=AAAAgAAAAAAAAA%3d%3d&. Accessed April 14, 2026. CMS. National Coverage Determination. Acupuncture for Osteoarthritis. https://www.cms.gov/medicare-coverage- database/details/ncd-details.aspx?NCDId=284&ncdver=1&bc=AAAAgAAAAAAAAA%3d%3d&. Accessed April 14, 2026. Specialty matched clinical peer review.