CurrentCentenePolicy CP.MP.92

Clinical Policy: Acupuncture

Defines medical necessity criteria for needle acupuncture when a covered benefit under Centene-affiliated health plans, including who may provide it, allowed indications, contraindications, and visit limits; states acupuncture is not supported for indications other than those listed.

Policy Summary

PayerCentene

PolicyClinical Policy: Acupuncture

Policy CodePolicy CP.MP.92

Change TypeRevisions and annual reviews (criteria updates, contraindication addition, terminology update)

Effective Date

Next Review Date

Key ActionDocument that acupuncture is provided by a licensed/accredited practitioner with specific acupuncture training, document the clinical indication matches an allowed indication, and document absence of listed contraindications.

SourceLink

POLICY UPDATE CHANGES

Criteria I.B.4 updated to headaches occurring ≥ 15 days per month for more than three months (07/23 revision).

Added contraindications of severe neutropenia and insertion at sites of active infection or malignancy (07/20 revision).

Replaced 'experimental/investigational' verbiage with 'current evidence does not support the use of acupuncture for indications other than those listed above' (08/21 revision).

5Covered Indications Listed

6Initial course

Coverage Summary

This policy defines medical necessity criteria for needle acupuncture when covered under Centene-affiliated health plans, including who may provide it, the allowed indications, contraindications, and visit limits. Acupuncture is described as manual and/or electrical stimulation of thin, solid, metallic needles inserted into the skin. Evidence supports effectiveness for postoperative or chemotherapy-induced nausea and vomiting, nausea and vomiting of pregnancy, certain pain conditions including chronic low back, neck, or shoulder pain, some headache disorders (specifically chronic migraines or moderate to severe chronic tension headaches occurring ≥ 15 days per month for more than three months), and pain from clinically diagnosed osteoarthritis of the knee or hip.

Covered Indications Listed5

Initial course6 visits / 1 month

Extension course if improved6 visits / 2 months

Headache frequency threshold≥ 15 days per month for more than three months

Medically Necessary Criteria

Not Supported Indications

Not supported indications

Not covered / not supported by current evidence:

ANY of the following

Use of acupuncture for indications other than the specific list in the medically necessary criteria (I.B.1-5) is not supported by current evidence

Terminology in the policy was updated to replace the phrase 'experimental/investigational' with the statement that current evidence does not support the use of acupuncture for indications other than those listed above. This change is a wording/terminology update and did not alter the coverage criteria.

Coding

Relevant CPT codes (informational)CPT

97810	Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97811	Acupuncture, one or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needle(s)
97813	Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814	Acupuncture, one or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needle(s)

Provider Actions & Documentation

Documentation Required

Provider qualifications

Document that acupuncture is provided by a licensed acupuncturist or appropriately licensed practitioner with acupuncture within their scope of practice and specific acupuncture training/credentialing.

Provider must be licensed and have specific acupuncture training/credentialing

Documentation Required

Indication documentation

Document the clinical indication and ensure it matches one of the allowed indications.

Postoperative or chemotherapy-induced nausea and vomiting
Nausea and vomiting of pregnancy
Chronic low back, neck, or shoulder pain

Background & Evidence

Acupuncture encompasses manual manipulation and/or electrical stimulation of thin, solid, metallic needles inserted into the skin and is one of the oldest forms of complementary and alternative medicine. Treatments typically involve evaluation followed by insertion of fine metal needles for periods ranging from about five to 20 minutes, with session frequency and total number of sessions varying by condition and severity.

Randomized controlled trials and systematic reviews provide evidence supporting acupuncture for management of postoperative and chemotherapy-related nausea and vomiting, some headache disorders (with a Cochrane review noting consistent additional benefit for migraine prevention), chronic musculoskeletal pain such as chronic low back, neck, or shoulder pain, and osteoarthritis pain—particularly of the knee (with guideline-level conditional recommendations for osteoarthritis of knee, hip, or hand). Evidence is insufficient or does not support acupuncture for many other indications.

Definitions

Evidence

Unsupported block type: item_list

Medicare Determinations

Name	Number	Effective Date	Type
National coverage determination: acupuncture	30.3	2020-01-21	NCD

Revision History

07/23non-material revisionLatest

Criteria I.B.4 updated to headaches occurring ≥ 15 days per month for more than three months; Criteria I.B.5 updated to include osteoarthritis of the hip; minor rewording in Criteria and Background sections with no impact on criteria.

07/20material revision

Added contraindications of severe neutropenia and insertion at sites of active infection or malignancy; criteria restructured (contradictions explicitly listed).

08/21non-material revision