Oscar Acupuncture (CG013) Form

Acupuncture as a Treatment Option

Acupuncture has been widely practiced for many years in various parts of the world. It involves the stimulation of specific body areas by penetrating the skin with fine needles. Stimulation can be accomplished electrically or manually.

Acupuncture has been suggested as a viable treatment option for a wide variety of acute and chronic pain conditions in both children and adults. However, determining the clinical utility of acupuncture has been challenging, largely related to the difficulties in designing studies with adequate blinding, controls, size and uniform outcome measures. Furthermore, acupuncture is a passive modality and as such should be used in conjunction with active rehab programs when applicable.

The Plan members may be eligible for acupuncture depending on their plan. Acupuncture is a considered medically necessary service only when used as a substitute for traditional anesthesia and for the treatment of certain conditions. The acupuncture must be provided by a provider practicing within the scope of his or her license, or state licensing requirements for practicing acupuncture. The Plan does not consider acupuncture for all other common indications medically necessary, unless otherwise directed by state regulation.

Definitions

• Acupuncture is one technique, within a family of procedures in traditional Chinese medicine, which involves the manual or electrical stimulation of sterilized, single-use needles, used to penetrate the skin on acupuncture points along the meridian lines. This therapy activates the body’s own self-repair mechanisms.
• Maintenance Therapy is the use of acupuncture as therapy in a member whose symptoms or condition is neither worsening nor improving, or is being maintained after treating the acute pain.

Clinical Indications

The Plan considers acupuncture as medically necessary if ALL of the following criteria are met:

1. Acupuncture is prescribed by and will be performed by an appropriately licensed provider practicing within the scope of his or her license; and
2. Medical records indicate ALL of the following criteria:
   • Diagnosis with date of onset or exacerbation of the disorder; and
   • Quantitative and objective short-term and long-term goals, which should include a reasonable estimate of when the goals will be reached and the frequency and expected duration of treatment.
3. Medical records indicate that ONE of the following criteria are met:
   • Acupuncture is being provided as an alternative to traditional perioperative anesthesia, including but not limited to: normal childbirth, dental procedures, and minor surgical procedures; or
   • The member has ONE of the following conditions:
     • Nausea and vomiting associated with pregnancy and childbirth; or
     • Nausea and vomiting associated with chemotherapy or anti-neoplastic therapy; ii. or
     • Postoperative nausea and vomiting; or iii.
     • Postoperative dental pain; or iv.
     • One of the following chronic pain conditions that has been diagnosed by a licensed medical practitioner (e.g., MD, DO, PA, NP) and lasted a minimum of 12 weeks duration:
       • Headaches(i.e., tension-type or migraines with or without aura) or temporomandibular disorder; or
       • Osteoarthritic knee or hip pain; or
       • Chronic cervical, thoracic and/or lumbosacral back pain.

Continuation of Services

• After 4 weeks (max two visits per week) of acupuncture therapy, a patient must show meaningful and considerable improvement (i.e., pain decreased by >50% and/or functional improvement) to continue therapy. Continuation of services without meaningful and considerable improvement is considered not medically necessary. Alternative treatments should therefore be evaluated. If all other treatments have been exhausted or are contraindicated, then continuation of services may be considered.
• After 12 weeks (max two visits per week) of acupuncture therapy, services are considered experimental and investigational. Acupuncture has only demonstrated efficacy for short-term improvement in symptoms. Acupuncture has not demonstrated efficacy in long-term or maintenance acupuncture therapy.

Experimental or Investigational / Not Medically Necessary

• Maintenance therapy for any condition is considered experimental and investigational by the Plan.
• Acupuncture point injections for any indication are NOT considered medically necessary by the Plan. Acupuncture point injections are considered experimental and investigational as there is insufficient evidence in the peer-reviewed literature documenting their effectiveness and long-term outcomes relative to established therapies.
• Acupuncture for any other indication is considered experimental, investigational, or unproven and these indications include, but are not limited to, the following:
  • Acute conditions or injuries [including whiplash]
  • Acquired brain injury
  • Addiction
  • Allergies
  • Asthma
  • Autism spectrum disorders
  • Carpal Tunnel Syndrome
  • Cervicogenic headache
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Depression
  • Diabetic gastroparesis
  • Erectile dysfunction
  • Facial spasms
  • Fatigue
  • Fibromyalgia
  • Hot flashes
  • Hypertension
  • Infantile colic and diarrhea
  • Infertility
  • Inflammatory Bowel Disease
  • Insomnia
  • Irritable Bowel Syndrome (IBS)
  • Mental disorders
  • Muscle weakness and/or myalgias
  • Neuropathic pain
  • Obesity
  • Peripheral neuropathy
  • Post Traumatic Stress Disorder (PTSD)
  • Raynaud's disease
  • Smoking cessation
  • Spasticity
  • Substance Use Disorders
  • Tennis elbow
  • Tic disorders
  • Tinnitus
  • Urinary incontinence
  • Xerostomia