Acupuncture - Medical Necessity Criteria
Criteria for documenting medical necessity of acupuncture
Is acupuncture medically necessary?
Acupuncture is medically necessary for some conditions — like chronic low back pain — but not for others.
If you have health insurance, it’s best to check with your insurance provider for which conditions they consider acupuncture medically necessary. The medical necessity criteria below can give you an idea as to what these conditions may be.
Medical necessity criteria for acupuncture
Acupuncture is generally considered medically necessary for people who have any of the following conditions:
- Nausea or vomiting after surgery
- Nausea or vomiting of pregnancy
- Nausea or vomiting due to chemotherapy
- Cancer pain
- Chronic* low back pain despite proper medication
- Chronic neck pain despite proper medication
- Chronic shoulder pain despite proper medication
- Chronic migraine despite proper medication
- Chronic tension headache** despite proper medication
- Pain caused by chronic osteoarthritis of the knee that affects the person’s ability to do their daily activities
- Pain caused by chronic osteoarthritis of the hip that affects the person’s ability to do their daily activities
Rarely, acupuncture may be considered medically necessary for these additional conditions:
- Anxiety ***
- Depression ***
- Detoxification ***
- Insomnia ***
- Menstrual disorders ***
- Pain after dental surgery
- Peripheral neuropathy
- Post-traumatic stress disorder ***
- Radiculopathy
- Reflex sympathetic dystrophy
- Restless legs syndrome ***
- Schizophrenia ***
- Smoking cessation ***
- Temporomandibular disorders
- Xerostomia (dry mouth) associated with radiation therapy or Sjogren’s syndrome ***
Take note that not all health plans cover acupuncture for all of the conditions listed above. For example, Health Net covers acupuncture for chronic osteoarthritis of the knee but not for chronic osteoarthritis of the hip. Aetna covers acupuncture for post-operative dental pain, but most other health plans don’t. Most health plans cover acupuncture for chronic low back pain but Blue Cross Blue Shield of North Dakota (Commercial and Medicaid) does not. Again, it’s important to check coverage and medical necessity criteria with your own health plan.
* For most of the conditions listed above, “chronic” is defined as lasting for 12 weeks or more.
** This is defined by some health plans as headaches that have been occurring again and again for more than 12 weeks, while other health plans specify that the headache must have been occurring in more than 14 days per month for more than 3 months.
*** Very rarely covered, e.g., by Minnesota Medicaid
Frequently asked questions
Why isn’t acupuncture covered by Medicare?
Actually, acupuncture is covered by Medicare, but only for chronic low back pain.
See the criteria listed below.
Does Medi-Cal cover acupuncture?
When acupuncture is medically necessary, Medi-Cal may cover it through its managed care programs such as Anthem Blue Cross.
Why isn’t acupuncture covered by insurance?
Actually, insurance does cover acupuncture, but only for certain conditions. Acupuncture must be considered medically necessary for those conditions and it must be done by a professional licensed to perform acupuncture.
Does Medicare cover acupuncture?
Medicare covers acupuncture only for individuals with chronic low back pain. All of the following criteria must be met:
- The low back pain has lasted for 12 weeks or longer.
- The low back pain has no identifiable cause — that is, it must not be due to infection, cancer, or another known condition.
- The low back pain must not be due to, or associated with, surgery.
- The low back pain must not be due to, or associated with, pregnancy.
If there are no signs of improvement, or if the back pain seems to be getting worse, Medicare says the acupuncture must be stopped.
Do health insurance plans cover acupuncture?
Acupuncture may be covered by health insurance plans under certain conditions. For acupuncture to be covered by insurance, health plans generally require that:
- the acupuncture is being done for a condition for which it is considered medically necessary (see above), and
- the acupuncture is being done by either:
- a licensed acupuncturist, or
- another licensed medical practitioner whose training and scope of practice includes acupuncture
How many acupuncture sessions are covered by insurance?
It varies. An initial course of acupuncture may be covered for six to twelve (6-12) visits, while six to eight (6-8) additional visits may be approved if the patient shows improvement in their condition after undergoing acupuncture.
Examples of initial and additional visits covered:
- Health Net
- Initial course of 6 visits over 1 month
- If condition improves, additional 6 visits over 2 months
- Medicare
- Up to 12 visits in 90 days
- If condition improves, additional 8 sessions
- No more than 20 sessions in a 12-month period
Documentation to submit
These are the things you can prepare documentation of in order to support your statement that _____ is medically necessary. Submit only those that apply.
Documentation of a medical condition for which _____ may be medically necessary:
Other documentation as applicable and needed:
Health plan criteria for acupuncture and other references
- Aetna Clinical Policy Bulletin on Acupuncture and Dry Needling
- Anthem Blue Cross Clinical UM Guideline on Acupuncture
- Blue Cross Blue Shield of North Dakota Medical Policy on Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence
- Centers for Medicare & Medicaid Services (CMS) National Coverage Determination on Acupuncture for Chronic Lower Back Pain (cLBP)
- Cigna Medical Coverage Policy on Acupuncture
- EmblemHealth Medicare HMO Plans Medical Policy on Acupuncture
- Geisinger Health Plan Medical Benefit Policy on Acupuncture
- Health Net (Centene Corporation) Clinical Policy on Acupuncture
- Mass General Brigham Health Plan Medical Policy on Acupuncture
- Minnesota Medicaid Policy on Acupuncture Services
- Paramount (Commercial, Medicare, and Medicaid) Policy on Acupuncture
- San Francisco Health Plan Coverage of Acupuncture
- Tufts Health Plan Acupuncture Payment Policy
- UHA Policy on Complementary and Alternative Medicine