CurrentAmeriHealth CaritasPolicy CCP.1155

Acupuncture

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This policy governs medical necessity and coverage criteria for acupuncture services provided to AmeriHealth Caritas members, specifying covered indications, limitations, and practitioner qualifications.

Policy Summary

PayerAmeriHealth Caritas

PolicyAcupuncture

Policy CodePolicy CCP.1155

Change TypeNo material change

Effective DateMay 20, 2025

Last ReviewMay 1, 2026

Next Review DateSep 1, 2027

Key ActionDocument that standard therapies were tried, not tolerated, or refused and ensure practitioner is appropriately trained and licensed when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 visitstreatment beyond this number requires medical director review

age ≥ 18primary adult age threshold for covered indications

up to 10NICE suggested course for headache

multipleevidence sources cited

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CurrentAmeriHealth CaritasPolicy CCP.1155

Acupuncture

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Policy Summary

PayerAmeriHealth Caritas

PolicyAcupuncture

Policy CodePolicy CCP.1155

Change TypeNo material change

Effective DateMay 20, 2025

Last ReviewMay 1, 2026

Next Review DateSep 1, 2027

Key ActionDocument that standard therapies were tried, not tolerated, or refused and ensure practitioner is appropriately trained and licensed when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 visitstreatment beyond this number requires medical director review

age ≥ 18primary adult age threshold for covered indications

up to 10NICE suggested course for headache

multipleevidence sources cited

commonly submitted codes listed

Coverage Criteria for Acupuncture

Medically Necessary Indications (Initial therapy)

Covered when ALL of the following are met:

Overall coverage conditions

Adult covered indications (age ≥ 18): One of the following medical conditions: chemotherapy-induced or postoperative nausea and vomiting; chronic (lasting >3 months) non-specific lower back pain; chronic migraine or tension-type headache.
See policy coverage list
Additional guideline-referenced covered indications: One of the following: chronic knee osteoarthritis; temporomandibular disorders; chronic pain, fatigue, or vasomotor symptoms related to cancer or cancer treatment; anticipatory nausea related to cancer treatment; and other cancer-related supportive indications noted by guideline sources.
Policy cites guideline sources for these indications

Pediatric indications (refer to guideline-specified ages): Where specified by guidelines: age 7–17 for chronic tension-type headache and migraine prophylaxis; age ≥1 for postoperative pain and postoperative nausea and vomiting (see guideline citations).

Pediatric indications listed in guidelines; coverage statement restricts main adult coverage to age ≥18

All uses of acupuncture not explicitly listed as covered in this policy are considered investigational or not medically necessary. In addition, maintenance treatment — defined as ongoing acupuncture when the member’s symptoms are neither regressing nor improving — is not medically necessary. Finally, treatment beyond five visits without meaningful improvement in symptoms requires review by a medical director and may be subject to denial if clinical improvement is not documented.

This policy has been periodically updated since its original effective date in 2015. Key revisions include expansion of coverage to acute or subacute lower back pain in 2/2018 and further coverage modifications in 4/2019, 5/2025, and 5/2026. Providers should note the revision history and apply the current coverage criteria to avoid claim denials stemming from reliance on outdated policy language.

Maintenance acupuncture provided when there is no documented improvement (and no documented regression) in the member’s condition is not medically necessary. The policy also specifies that children should not receive acupuncture for nausea and vomiting while under anesthesia. Treatment that exceeds five visits without meaningful symptomatic improvement requires medical director review and may be denied if improvement is not demonstrated.

Conservative Therapy and Documentation Requirements

Documentation that standard therapies were tried, not tolerated, or refused is required.

Documentation that standard therapies were tried, were not tolerated, or were refused is required.

Conservative therapy documentation requirement: Documentation in the medical record must state that standard therapies for the condition were attempted and either: (a) provided inadequate control of symptoms, (b) were not tolerated by the member, or (c) were refused by the member.

Supports adjunctive-use requirement from policy and guideline context

Practitioner qualification: Medical record must document the practitioner is appropriately trained and licensed in acupuncture (state licensure or relevant board certification as applicable).

See policy requirement for qualified practitioner

Additional conservative-treatment criteria (placeholder for related required nodes)

Additional conservative-treatment criteria that may be relevant to coverage decisions:

Visit Limits and Frequency Guidance

Acupuncture frequency limits

Visit limitTreatment beyond five visits requires review by a medical director (prior authorization or medical director review may be required).

NICE guidance for headacheNICE suggests considering up to 10 sessions of acupuncture over five to eight weeks for chronic tension-type headache and migraine prophylaxis when first‑line drugs are ineffective or not tolerated (persons >12 years).

Maintenance treatmentMaintenance acupuncture when symptoms are neither regressing nor improving is not medically necessary.

Additional frequency/limit notes

ApplicabilityFrequency limits apply to outpatient acupuncture services as described in policy CCP.1155; lack of adherence to current coverage criteria may result in claim denial.

Pediatric caution

Related Codes and Billing

Related codesCPT

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with 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 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).
20560	Needle insertion(s) without injection(s); 1 or 2 muscle(s).
20561	Needle insertion(s) without injection(s); 3 or more muscles [dry needling].

Provider Actions, Authorization, and Documentation

Prior Authorization

Medical director review required for >5 visits

Treatment beyond five visits without meaningful improvement requires review by a medical director; prior authorization or medical director review may be required per plan.

Billing Rule

Prior authorization and commonly submitted CPT codes

Follow the policy's coverage and payer requirements when submitting acupuncture and related needling codes; commonly submitted CPT codes include 97810, 97811, 97813, 97814, 20560, and 20561.

Consult plan prior authorization requirements before submission where applicable.
Bill using the listed CPT codes for acupuncture and dry needling as appropriate.

Definitions and Procedure Descriptions

Definition of Acupuncture

DefinitionAcupuncture is a traditional Chinese medicine practice using needle insertion at mapped points to correct imbalances in the flow of 'qi' and improve health; needles are regulated as Class II medical devices (21 CFR 880.5580).

Core componentsCore elements include acupuncture needles, target location mapped by TCM, depth of needle insertion, and stimulation of the inserted needle.

Modalities includedModalities may include manual needle stimulation, electrical stimulation (electroacupuncture), low‑power lasers, heat, magnets, and ultrasound.

Safety considerationsWhen performed by qualified practitioners, adverse effects are similar to other needle procedures (infection, bleeding, nerve injury, pneumothorax) and are uncommon; caution with active infection, severe neutropenia, or implantable cardioverter‑defibrillators and electromagnetic stimulation.

Acupuncture without electrical stimulation (CPT 97810/97811)

Imaging and Diagnostic Requirements

Note

Imaging/prerequisite requirements — none specified in policy

No specific imaging prerequisites are listed in the policy; follow any procedure-specific payer requirements if applicable and check prior authorization guidance.

Not Covered / Investigational Uses

Uses of acupuncture that are not included among the policy’s listed covered indications are considered not covered because they are investigational or unproven. The policy explicitly states that maintenance acupuncture — ongoing treatment when symptoms are neither improving nor regressing — is not medically necessary. Additionally, pediatric use for nausea/vomiting under anesthesia is specifically identified as not appropriate.

Background and Evidence Summary

Acupuncture is a practice of traditional Chinese medicine involving insertion and stimulation of needles at mapped points to address symptoms and restore balance. This policy reflects evolving evidence and guidelines; it has undergone multiple updates since 2015, with coverage expansions and modifications noted in the policy history. Acupuncture is regarded as a generally safe, noninvasive adjunctive therapy when performed by qualified practitioners, but its use outside listed indications remains investigational per the policy.

Policy Revision History

2015-01initial_review

Initial review conducted and clinical policy effective date established in April 2015.

2016references_update

Policy references were updated.

2017references_update

Policy references were updated.

Policy Summary

PayerAmeriHealth Caritas

PolicyAcupuncture

Policy CodePolicy CCP.1155

Change TypeNo material change

Effective DateMay 20, 2025

Last ReviewMay 1, 2026

Next Review DateSep 1, 2027

Key ActionDocument that standard therapies were tried, not tolerated, or refused and ensure practitioner is appropriately trained and licensed when requesting coverage.

SourceLink

On This Page

Guideline-based sequencing: Where guideline recommendations exist (e.g., for migraine prophylaxis or chronic low back pain), acupuncture should be considered after recommended first-line pharmacologic or nonpharmacologic treatments have been tried and found ineffective or not tolerated.

Reflects guideline emphasis on adjunctive use and sequencing

Visit limit and review: Treatment beyond five visits without meaningful improvement requires review by a medical director; continuation beyond this may require prior authorization per plan procedures.>5 visits

Policy requires medical director review for continued treatment

Frequency and course considerations: When guideline-specified courses exist (e.g., up to 10 sessions over 5–8 weeks for chronic tension-type headache or migraine prophylaxis per NICE), the documented plan of care should align with those recommendations where clinically appropriate.up to 10 sessions over 5–8 weeks

NICE guideline referenced in policy

Children should not be treated with acupuncture for nausea and vomiting while under anesthesia.

Policy updatesPolicy coverage and limits have been modified over multiple updates through 5/2026—providers should reference the current policy version for plan-specific prior authorization requirements.

Step Therapy

Acupuncture only as adjunct after standard treatment

Acupuncture is covered as an adjunctive treatment option when standard treatment inadequately controls symptoms, is not tolerated, or is refused — documentation should indicate that standard therapies were tried, not tolerated, or refused.

Ensure records show prior standard therapy attempts, intolerance, or refusal before billing for acupuncture as adjunctive care.

Note

Document clinical rationale and treatment response

Document clinical rationale and member-specific details supporting medical necessity for acupuncture, including indication, symptom response, and any prior therapies, to reduce risk of denial.

Include indication from the policy's covered list (e.g., chronic low back pain, chronic migraine, chemotherapy-induced nausea).
Record symptom trajectory to support requests for more than five visits or ongoing care.

Documentation Required

Practitioner qualifications and adjunctive-use documentation

Documentation must show the practitioner is appropriately trained and licensed in acupuncture and that acupuncture is being used as adjunctive treatment after standard therapies inadequately control symptoms, are not tolerated, or are refused.

Include practitioner licensure/credentialing details and training in the record.
State explicitly that acupuncture is adjunctive to prior standard treatments (or why standard treatment was not used).

Billing Rule

Coding and billing — consult coding manuals

Consult current coding manuals and bill according to the commonly submitted CPT codes listed in the policy; the policy identifies 97810, 97811, 97813, 97814, 20560, and 20561 as the most commonly submitted codes.

Ensure unit/time reporting follows CPT guidance for initial and additional 15-minute acupuncture codes (+97811, +97814).
Differentiate between acupuncture codes and dry needling codes (20560/20561) when billing.

Denial Risk

Visit limits and maintenance treatment denial risk

Treatment beyond five visits without meaningful improvement triggers medical director review and maintenance treatment with neither regression nor improvement is not medically necessary — continued visits risk denial.

If symptoms are not improving, do not bill for ongoing maintenance care without documentation that meets medical director review criteria.

Denial Risk

Risk of denial from outdated coverage criteria

Coverage has changed through multiple policy updates; failing to follow the current coverage criteria may result in claim denial.

Verify you are following the policy current as of the recent review date (5/2026) when submitting claims.

CPT codes97810 — Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one‑on‑one contact with patient.

Additional unit+97811 — Acupuncture without electrical stimulation, each additional 15 minutes, with re‑insertion of needle(s) (listed in addition to the primary procedure).

Billing noteProviders should consult coding manuals and bill according to these codes as commonly submitted for acupuncture services under CCP.1155.

Acupuncture with electrical stimulation (CPT 97813/97814)

CPT codes97813 — Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one‑on‑one contact with patient.

Additional unit+97814 — Acupuncture with electrical stimulation, each additional 15 minutes, with re‑insertion of needle(s) (listed in addition to the primary procedure).

Clinical noteElectrical stimulation (electroacupuncture) is captured by the 97813/97814 code pair when used with acupuncture needle insertion.

Dry needling / trigger point needle insertion (CPT 20560/20561)

CPT codes20560 — Needle insertion(s) without injection(s); 1 or 2 muscle(s).

CPT codes20561 — Needle insertion(s) without injection(s); 3 or more muscles (dry needling).

Service descriptionThese codes describe trigger‑point or dry‑needling procedures that involve needle insertion without injection and are reported separately from acupuncture CPT codes when applicable.

2018-02coverage_change

Coverage changed to include acute or subacute lower back pain.

2019-04coverage_expansion

Policy references updated, policy ID changed, and coverage expanded.

2020-02references_update

Policy references were updated.

2021-04coverage_change

Policy references updated and Medicare coverage expanded.

2022-05references_update

Policy references were updated.

2023-05references_update

Policy references were updated.

2024-05references_update

Policy references were updated.

2025-05coverage_modified

Policy references updated and coverage modified.

2026-05coverage_modifiedLatest

Policy references updated and coverage modified (most recent update).