Sunflower Health Plan Acupuncture (PDF) Form

Acupuncture involves the manual and/or electrical stimulation of thin, solid, metallic needles inserted into the skin. Acupuncture has been studied for the treatment of many conditions, but some of the more common and studied indications include pain, nausea and vomiting, hypertension, chronic obstructive pulmonary disease, allergic rhinitis and addictive behavior. Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that, when a covered benefit under the benefit plan contract, needle acupuncture is medically necessary when meeting all of the following: A. Provided by a licensed acupuncturist or other appropriately licensed practitioner for whom acupuncture is within the practitioner’s scope of practice and who has specific acupuncture training or credentialing; B. Requested for one of the following: 1. Postoperative or chemotherapy induced nausea and vomiting; 2. Nausea and vomiting of pregnancy; 3. Chronic low back, neck, or shoulder pain; 4. Chronic migraines or moderate to severe chronic tension headaches, defined as headaches >14 days per month for more than 3 months; 5. Pain from clinically diagnosed osteoarthritis of the knee; C. None of the following contraindications: 1. Severe neutropenia as seen after myelosuppressive chemotherapy; 2. Insertion of acupuncture needles at sites of active infection or malignancy. An initial course of 6 visits over 1 month is considered medically necessary. If improvement in the condition occurs following the initial course of treatment, an additional 6 visits over 2 months is considered medically necessary to maintain improvement. II. It is the policy of health plans affiliated with Centene Corporation that current evidence does not support the use of acupuncture for indications other than those listed above. Background Acupuncture is a form of complementary and alternative medicine (CAM) and one of the oldest medical procedures in the world. It encompasses a large array of styles and techniques, however, the techniques most frequently used and studied are manual manipulation and/or electrical stimulation of thin, solid, metallic needles inserted into skin.1 The typical acupuncture treatment begins with identification of the patient's constitutional pattern. Once the diagnosis is established, fine metal needles are inserted into precisely defined points to correct disruption in harmony. Needles are removed after being in place for 10 to 15 Page 1 of 7 CLINICAL POLICY Acupuncture CEN"l'.'ENE" ~·orporatwn minutes while the patient lies relaxed. Treatments can occur one to two times a week and the total number of sessions is variable dependent on the condition, disease severity and chronicity. Acute conditions are typically treated with acupuncture two to three times a week for two to three weeks then frequency is gradually reduced until treatment is no longer needed. Generally, treatment will last for two to three months. There is insufficient evidence in studies to establish a defined treatment protocol for any condition.1 There are many proposed models for the mechanism of action of the effects of acupuncture; however, the data have been either too inconsistent or inadequate to draw significant conclusions. The theory in regards to the analgesic effect of acupuncture, associates the neurotransmitter effects such as endorphin release at both the spinal and supraspinal levels. Functional MRI studies have demonstrated various physiologic effects, associating acupuncture points with changes in brain MRI signals. Another theory is that acupuncture points are associated with anatomic locations of loose connective tissue.1 Evidence from a number of randomized, blinded, placebo-controlled studies indicate that acupoint stimulation can be effective in the management of postoperative nausea and vomiting, particularly in women, with mixed results in pediatric populations. Acupoint stimulation for women undergoing chemotherapy also reduced nausea and vomiting in some studies, but no effect was reported in a study involving both men and women. The evidence regarding alleviation of morning sickness by acupoint stimulation is limited, less rigorous than for postoperative nausea and vomiting, and ambiguous.5,9 Recent data on acupuncture for postoperative dental pain is limited, but earlier evidence indicated promising results for this use. Data was most promising for pain relief following tooth extraction.1,17 There are a number of randomized controlled trials that establish improvement in headache frequency, intensity, response, use of relief medication and quality of life relative to usual care and relief treatment only. An updated Cochrane Review that previously noted promising, but insufficient evidence in support of acupuncture for migraine headache indicates, “there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care,” following the completion of 12 additional trials.10 However, according to Hayes, ambiguity remains due to the low quality of the evidence and the variety of the studies evaluated, considering the diversity in acupuncture technique, number of treatment sessions, and length of follow-up.15 Acupuncture for osteoarthritis pain appears to be effective, particularly for pain in the knee. Recent literature has shown relief of pain and improved function in osteoarthritis of the knee for patients treated with acupuncture.1,8 Acupuncture has been studied for a variety of other reasons, but studies and evidence does not currently support its use for indications such as, but not limited to, arm pain, temporomandibular joint dysfunction, menstrual cramps and fibromyalgia.1,6 Coding Implications Page 2 of 7 CEN"l'.'ENE" ~·orporatwn CLINICAL POLICY Acupuncture This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT®* Codes 97810 97811 97813 97814 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needles(s) Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needles(s) - Migraine Chronic tension- type headache ICD-10-CM Diagnosis Codes that Support Coverage Criteria + Indicates a code(s) requiring an additional character ICD 10 CM Code - G43.001through G43.919 G44.221 through G44.229 M17.0 through M17.9 M25.511through M25.519 M50.00 through M54.9 O21.0 through O21.9 R11.10 through R11.2 Excessive vomiting in pregnancy Osteoarthritis of knee Nausea and vomiting Other dorsopathies Pain in shoulder Reviews, Revisions, and Approvals Bibliography reviewed and updated Reworded medically necessary timeframes. No criteria changes made Reformatted criteria, adopted new template Reference reviewed and no criteria changes made Integrated with Health Net acupuncture policy. Removed (adults and children) from I.A; removed acute post-operative dental pain; maintained Revision Date 11/14 01/15 12/15 Approval Date 12/14 12/15 10/16 11/16 Page 3 of 7 CLINICAL POLICY Acupuncture Reviews, Revisions, and Approvals neck and shoulder pain, and only osteoarthritis of knee. Did not incorporate list of investigational procedures since it is not all inclusive. References reviewed and updated. Changed continuation criteria to remove statement that continued treatment after the initial 2 months is not medically necessary. References reviewed and updated. References reviewed and updated. Specialist review. Restructured criteria with no changes to wording. Added contraindications of severe neutropenia or malignancy or infection at the site of insertion. Removed the “+” from M54.9 and R11.2 and added “.10” to R11.0. References reviewed and updated. Annual review. “Experimental/investigational” verbiage replaced in policy statement with “current evidence does not support the use of acupuncture for indications other than those listed above.” Updated background with no impact on criteria. Replaced “member” with “member/enrollee” throughout document. Reordered background. References reviewed, updated with AMA format applied. Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date.” Reviewed by specialist. Annual review completed. Updated background with no impact to clinical criteria. References reviewed and updated. CEN"l'.'ENE" ~·orporatwn Revision Date Approval Date 11/17 11/17 09/18 08/19 07/20 09/18 09/19 08/20 08/21 08/21 07/22 07/22