Complementary and Alternative Medicine
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This policy governs medical necessity determinations for complementary and alternative medicine interventions for Network Health Plan members (Commercial and Medicare) and provides utilization management guidance for UMC nurses. Providers should consult individual member coverage documents prior to applying criteria.
No changes were made to content or utilization guidance; references and codes were updated.
Coverage and Medical Necessity Criteria
General Medical Necessity Guidance
Policy-level determinations and routing guidance
Applies to Commercial and Medicare lines of business; Medicare follows CMS NCD/LCD where applicable.
No changes were made to content or utilization guidance during the annual review; references and CPT verification were updated.
MCG 30th edition has no guidance specific to H-wave or interferential therapy; no CMS NCD/LCD identified for these therapies.
CMS guidance exists for chiropractic services (LCA A57889 and Medicare Benefit Policy Manual).
No national or local coverage determinations were identified from the Centers for Medicare & Medicaid Services (CMS) pertaining to H-wave or interferential therapy. Additionally, MCG (30th edition) provides no guidance specific to these therapies. Use of these modalities should be evaluated against current peer‑reviewed evidence and the member's specific coverage document when determining medical necessity.
This document does not specify any technologies that are categorically not medically necessary. Determinations about medical necessity for complementary and alternative medicine interventions depend on the available evidence and on the member's individual plan coverage. UMC staff and providers must consult the member’s coverage document and applicable evidence when making coverage decisions.
CPT / HCPCS Verification
| CPT/HCPCS | CPT/HCPCS codes were verified/updated as part of the annual review (specific codes not listed in this summary). |
Provider and UMC Staff Actions
Use policy with member coverage
Utilization Management Coordinator (UMC) nurses must use this Complementary and Alternative Medicine policy when determining medical necessity and follow the member's plan-specific coverage documents; prior authorization may be required according to those plan documents.
- UMC staff consult the member's individual coverage document regarding plan coverage prior to applying medical necessity criteria for Commercial lines of business.
- Policy guidance is used by UMC nurses to determine medical necessity; providers must follow plan-specific coverage documents and any prior authorization rules in the member's plan.
Route biofeedback to eviCore
Biofeedback is not governed by this policy alone; it is managed via eviCore criteria as part of physical and occupational therapy services, so route requests to eviCore for review.
- Biofeedback is addressed through eviCore criteria as a component of physical and occupational therapy services.
Verify individual member coverage
Before applying medical necessity criteria, UMC staff must review the individual member's coverage document to confirm plan-specific benefits and limitations.
- UMC staff consult the member's individual coverage document regarding plan coverage prior to applying medical necessity criteria for Commercial lines of business.
Consult member-specific coverage for plan applicability
No utilization guidance or policy content was changed in this review; UMC staff should consult the member's individual coverage document for plan-specific determinations rather than relying on this policy alone.
- Annual review made no changes to content or utilization guidance; consult member-specific coverage for plan applicability.
Background and Context
Complementary and Alternative Medicine (CAM) includes medical products and practices that are not part of standard medical care but may be used alongside or in place of conventional therapies. This policy provides utilization management guidance for CAM modalities discussed in the document—such as H‑wave, interferential therapy, acupuncture, biofeedback, and chiropractic services—and notes that some CAM interventions may be considered medically necessary only when safety and effectiveness are supported by current peer‑reviewed literature.
Key Terms and Definitions
Frequency and Visit Limits
Imaging and Diagnostic Requirements
No imaging required for CAM interventions
This policy does not specify any imaging prerequisites for complementary and alternative medicine (CAM) interventions; no imaging is required per the document.
- "No national or local coverage determinations were identified..." and the policy provides no imaging requirements for CAM interventions.
Not Medically Necessary / Exclusions
The policy does not list explicit exclusions or procedures that are universally not covered. Coverage determinations for specific CAM procedures are subject to the strength of the evidence and the member’s individual plan benefits; UMC staff should verify plan coverage before applying medical necessity criteria.
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