Blue Cross Blue Shield RI Acupuncture Coverage Update

Coverage Summary

This policy covers acupuncture and dry needling for Medicare Advantage members under Blue Cross Blue Shield Rhode Island, defining provider qualifications, coding, limits, and exclusions. It applies to initial evaluations for new patients and ongoing acupuncture or dry needling visits. High-level visit limits: up to 20 visits for chronic low back pain (cLBP) and up to 12 visits per calendar year for all other indications. The coverage stance is mixed, with specific covered uses and explicit exclusions noted.

Thresholds and Quick Facts

Chronic Low Back Pain Visit Limit<= 20 visits

Other Indications Annual Visit Limit<= 12 visits per calendar year

Initial Evaluation AllowedCPT 99202-99205 for new patients only

Medical-Necessity Criteria

General Coverage / Provider Qualifications

Acupuncture and an initial evaluation (for a new patient) is covered when rendered by a licensed provider for covered indications:

Provider types: Provider is a licensed doctor of acupuncture (D.Ac) or physician (MD or DO) and may furnish acupuncture in accordance with applicable state requirements.
Supported by provider qualification statements.
Other clinicians: Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by ACAOM.
ACAOM accreditation requirement cited.
Initial evaluation (new patient): An initial evaluation (CPT 99202-99205) is allowed only for new patients (no professional services from the physician within the past three years).
New patient definition per CPT guidelines.
E/M same-day billing: E/M should not be filed on same date as acupuncture unless Modifier -25 applies; acupuncture codes 97810/97811 include associated E/M elements as part of the treatment.

Acupuncture for Chronic Low Back Pain (cLBP)

Covered when ALL of the following are met:

Diagnosis requirement: Diagnosis meets CMS definition of chronic low back pain (cLBP).
CMS defines cLBP per referenced NCD.
Exclusions for cLBP: cLBP must not be associated with surgery, pregnancy, metastatic, inflammatory, infectious, or other excluded causes.
Specific exclusions listed in policy.
Visit limit: Limit: Up to 20 acupuncture or dry needling visits are covered for cLBP; services greater than 20 are not covered.<= 20 visits
Visit limit includes acupuncture and dry needling.

Acupuncture for All Other Indications

Covered when ALL of the following are met:

Indication requirement: Indication is not chronic low back pain and is otherwise a covered indication per member benefit.
Member benefit applicability noted.
Visit limit: Limit: Up to 12 acupuncture visits per calendar year for indications other than cLBP; services greater than 12 visits are not covered.<= 12 visits per calendar year
Benefit limit for all other indications.

Dry Needling / Needling

Coverage statements for needling:

Dry needling for cLBP: Dry needling for chronic low back pain is included in the cLBP limit (up to 20 visits).<= 20 visits
Policy explicitly includes dry needling in cLBP visit limit.
Dry needling for other conditions: Dry needling (needling) for any condition other than chronic low back pain is not covered.
Non-coverage for needling outside cLBP.

Not Covered / Exclusions

The following are not covered:

Anesthetic during surgery: Acupuncture when used as an anesthetic during a surgical procedure is not covered.
Adjunctive therapies not covered: Adjunctive therapies such as moxibustion, herbs, oriental massage, etc., are not covered.
Precious metal needles (e.g., gold, silver) are not covered.
Other non-listed services: Any other service not specifically listed as a covered service is not covered.

Coding

Covered Acupuncture / Dry Needling CPT Codes (cLBP)CPTCovered

97810	Acupuncture; 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97813	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)
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)
20561	Needle insertion(s) without injection(s); 3 or more muscles
20560	Needle insertion(s) without injection(s); 1 or 2 muscles

Covered Acupuncture CPT Codes (All Other Indications)CPTCovered

97810	Acupuncture; 1 or more needles; without 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)

Evaluation and Management Codes (separately identifiable only)CPTCovered

99202	Office or other outpatient visit for the evaluation and management of a new patient
99203	Office or other outpatient visit for the evaluation and management of a new patient
99204	Office or other outpatient visit for the evaluation and management of a new patient
99205	Office or other outpatient visit for the evaluation and management of a new patient
99211	Office or other outpatient visit for the evaluation and management of an established patient; may not require presence of a physician or other QHP
99212	Office or other outpatient visit for the evaluation and management of an established patient
99213	Office or other outpatient visit for the evaluation and management of an established patient
99214	Office or other outpatient visit for the evaluation and management of an established patient
99215	Office or other outpatient visit for the evaluation and management of an established patient

Provider Actions

Documentation Required

Provider Qualifications and Documentation

Ensure provider meets applicable state requirements. Licensed doctors of acupuncture (D.Ac) or physicians (MD/DO) may furnish acupuncture per state rules. PAs, NPs/CNSs, and auxiliary personnel may furnish acupuncture only if they meet state requirements and hold a masters or doctoral level degree in acupuncture or Oriental Medicine from an ACAOM-accredited school. Document and verify new patient status (a patient who has not received any professional services from the physician within the past three years) to bill initial evaluation codes 99202-99205.

Verify state licensure and scope before furnishing acupuncture.
Confirm ACAOM-accredited masters or doctoral degree when applicable for PAs/NPs/auxiliary personnel.
Document new patient status per CPT (no professional services from the physician in the past 3 years) to bill 99202-99205.

Background and Evidence

Acupuncture includes insertion and manipulation of needles and multiple variations such as shallow, intradermal, or intramuscular needling, which may produce sensations like numbness, tingling, electrical sensation, fullness, distension, soreness, warmth, or itching; practitioners may seek sensations of tenseness or a dragging feeling by twirling, plucking, or thrusting needles. Dry needling is considered within the same modality spectrum for cLBP and is included under the cLBP visit limit. The policy references CMS national coverage determinations for acupuncture, including the NCD for Acupuncture for Chronic Low Back Pain (30.3.3) and related NCDs for other indications.

NCD Name	NCD Number/Type
Acupuncture for Chronic Low Back Pain	30.3.3 (NCD)
Acupuncture	30.3 (NCD)
Acupuncture for Fibromyalgia	30.3.1 (NCD)
Acupuncture for Osteoarthritis	30.3.2 (NCD)

Definitions

New patient: per CPT guidelines and this policy, a new patient is a patient who has not received any professional services from the physician within the past three years.

cLBP: chronic low back pain (cLBP) is defined as the CMS definition referenced in the policy and used to determine eligibility for the cLBP-specific coverage and the up to 20 visit limit for acupuncture or dry needling.

Revision History

2021-01-01effective_date

Policy effective date 01/01/2021.

2022-06-15policy_last_updatedLatest

Policy last updated 06/15/2022.

2022-08publication

Published in Provider Update August 2022.

OpenPayer

Payment Policy Acupuncture and Needling Services Medicare Advantage Plans Dry