Cigna Acupuncture Coverage Update

Coverage Summary

This policy defines when acupuncture services are covered, not covered, or considered experimental for members whose benefit plan includes acupuncture. Acupuncture is considered medically necessary for specific indications (including tension-type headache and migraine; musculoskeletal joint and soft tissue pain causing functional deficit; and certain nausea indications when co-managed by a medical physician) when ALL specified medical necessity and treatment planning/outcome criteria are met (see policy for the full list).

Acupuncture is considered not medically necessary for services intended to improve or maintain general physical condition, for maintenance acupuncture when significant therapeutic improvement is not expected, for services that do not require the skills of a qualified provider (e.g., independently performed activities or home exercise programs), and for any other indication not listed as medically necessary (including infertility and recurrent pregnancy loss).

Acupuncture point injection therapy (pharmaceuticals or biologics injected into acupuncture points) is considered experimental, investigational or unproven due to insufficient evidence of safety and efficacy.

Coverage under this policy applies only when acupuncture benefits are included in the member's applicable benefit plan; benefits are determined by the plan document and applicable laws/regulations. Effective date: 4/15/2025. Next review date: 4/15/2026.

Quick Reference — Thresholds & Operational Items

Therapeutic trial durationInitial trial 2–4 weeks; if no improvement documented after 2–4 weeks consider alternative treatment plan

FOM MCID requirementWhen used, Functional Outcome Measures (FOMs) must demonstrate Minimal Clinically Important Difference (MCID) from baseline on periodic reassessments

Typical WOMAC durabilityKnee OA improvements may persist ~3–6 months post-treatment (varies by comparator and study)

Note about MCID examplesMCID varies by measure and study; some trials exceed MCID (e.g., VAS/HFAQ/WOMAC) while others do not — correlate with clinical presentation

Required provider qualificationsServices must be delivered by a qualified provider of acupuncture acting within scope of state/federal license, certification, or registration

Required CPT codesBill acupuncture with CPT codes 97810, 97811, 97813, 97814 (acupuncture point injection CPTs 20550–20553 considered experimental/unproven)

Medical‑Necessity Criteria

Medically Necessary

If coverage for acupuncture services are available in the applicable benefit plan document, acupuncture may be provided as treatment for ANY of the following conditions when ALL of the medical necessity factors and ALL of the treatment planning /outcomes listed below are met:

Tension-type Headache; Migraine Headache with or without Aura

Musculoskeletal joint and soft tissue pain (e.g., hip, knee, spine) resulting in a functional deficit (e.g., inability to perform household chores, interference with job functions, loss of range of motion)

Nausea Associated with Pregnancy (only when co-managed)

Post-Surgical Nausea (only when co-managed)

Nausea Associated with Chemotherapy; (only when co-managed)

Coding

Acupuncture CPT codes referencedCPTCovered

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, when performed
97813	Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, when performed

Covered CPT (when criteria met)CPTCovered

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97811	Acupuncture, each additional 15 minutes; without electrical stimulation, 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 the patient.
97814	Acupuncture, each additional 15 minutes; with electrical stimulation, with re-insertion of needle(s) (List separately in addition to code for primary procedure).

Experimental/Unproven CPT (Acupuncture Point Injection)CPTExperimental

20550	Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar 'fascia') — considered experimental/unproven when used to report acupuncture point injection therapy.
20551	Injection(s); single tendon origin/insertion — considered experimental/unproven when used to report acupuncture point injection therapy.
20552	Injection(s); single or multiple trigger point(s), 1 or 2 muscles — considered experimental/unproven when used to report acupuncture point injection therapy.
20553	Injection(s); single or multiple trigger point(s), 3 or more muscles — considered experimental/unproven when used to report acupuncture point injection therapy.

Covered ICD-10-CM Diagnosis CodesICD-10Covered

G43.001-G43.919	Migraine.
G44.201	Tension-type headache, unspecified, intractable.
G44.209	Tension-type headache, unspecified, not intractable.
G44.211	Episodic tension-type headache, intractable.
G44.219	Episodic tension-type headache, not intractable.
G44.221-G44.229	Chronic tension-type headache.
G44.301-G44.329	Post traumatic headache.
G89.11	Acute pain due to trauma.
G89.12	Acute post-thoracotomy pain.
G89.18	Other acute postprocedural pain.

1–10 of 40

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Not Medically Necessary ICD-10-CMICD-10Not Covered

All other codes

All ICD-10-CM diagnosis codes not specifically listed as 'Considered Medically Necessary' in this policy portion.

Provider Actions & Documentation

Documentation Required

Initial evaluation documentation required

Initial evaluation must document clinical history, exam, medical decision-making; subjective historical evaluation (e.g., 10 questions); standardized and non-standardized tests; baseline functional status; working diagnosis; plan of care with frequency/duration; measurable goals; prognosis and discharge plan.

Clinical history, examination, and medical decision‑making
Subjective historical evaluation using standardized method (e.g., 10 questions)
Specific standardized and non‑standardized tests and assessments
Interpretation/synthesis of findings and working diagnosis
Plan of care with specific techniques, frequency and duration
Functional, measurable, time‑framed short‑ and long‑term goals
Prognosis and estimated discharge plan

Documentation Required

Treatment session documentation required

Background & Evidence Summary

Acupuncture is a complementary medicine practice that stimulates specific anatomic skin locations by penetrating fine needles to relieve pain or treat disease; stimulation may be manual or via electrical stimulation (electroacupuncture).

Multiple centrally mediated mechanisms have been proposed (e.g., release of endogenous opioids, diffuse noxious inhibitory control, descending serotonergic pathways, autonomic modulation of inflammation), but the precise physiological mechanism remains not definitively established.

The FDA considers acupuncture safe when performed by qualified practitioners using sterile, single-use, nontoxic needles labeled for single use; overall acupuncture has a relatively low rate of serious adverse events when performed per recommendations. Licensure or registration for acupuncture providers exists in most states, but scope of practice and which practitioner types may deliver acupuncture vary by jurisdiction.

A typical course of acupuncture may last several weeks; there is no consensus on optimal number of treatments, but clinical improvement should be expected. If no improvement after an initial trial of two–four weeks is documented, an alternative treatment plan should be considered, and continuation should be contingent on objective evidence of progress toward defined functional goals.

Evidence Source	Key Finding
Vickers et al. (2012) meta-analysis	Acupuncture superior to sham and no‑acupuncture controls for chronic pain; modest effect vs sham (≈0.15–0.23 SD) and larger vs no‑acupuncture (≈0.42–0.57); n≈17,922
NICE guideline (2021)	Mixed‑quality evidence: short‑term clinically important benefits vs sham/usual care for pain, QoL and function in some comparisons; certainty variable across outcomes and timepoints
Knee osteoarthritis (Cochrane & recent reviews)	May improve pain and function up to ~3–6 months post‑treatment versus sham, usual care, or some comparators; evidence low to very low certainty; adverse events generally mild (e.g., hematoma)
Tension‑type headache / Migraine (Cochrane reviews)	Trials/meta‑analyses show reduced headache frequency and pain vs routine care; mixed results vs sham with some trials favoring acupuncture; considered a valid nonpharmacologic option
Low back pain (systematic reviews/AHRQ)	Modest short‑term pain relief and some functional improvement vs sham or no treatment; certainty ranges low to moderate; effects often small and sometimes not clinically important
Chronic sciatica (Tu et al. 2024 RCT)	Acupuncture reduced leg pain (VAS) and ODI vs sham with benefits persisting to 52 weeks; no serious adverse events reported
Chemotherapy‑induced peripheral neuropathy (CIPN) reviews/meta‑analyses	Multiple reviews suggest benefit for pain, QoL and nerve conduction; evidence quality low to very low; acupuncture+electrical stimulation may be most effective
Nausea / P6 stimulation and CINV / PONV (Cochrane & trials)	Acupuncture and P6 stimulation effective for prevention/treatment of postoperative and chemotherapy‑induced nausea/vomiting; evidence often low certainty but consistent across many RCTs
Breast cancer / AI‑related arthralgia (Hershman et al., Mao/ASCO guidance)	RCTs and guidelines recommend acupuncture for aromatase inhibitor‑related joint pain; randomized trial showed reduced pain at 52 weeks
Acupuncture point injection therapy	Insufficient peer‑reviewed evidence to support safety and efficacy; considered experimental/investigational/unproven (policy conclusion)
Systematic evidence syntheses (multiple SRs/MAs)	Heterogeneous literature across conditions: benefits often small, variable durability, generally few serious adverse events; many trials small/low quality
Temporomandibular disorder (Busse et al. 2023)	Guideline issued conditional recommendation in favor of acupuncture for chronic TMD pain based on comparative effectiveness review
Durability analyses (meta‑analyses)	Some conditions (e.g., KOA, chronic pain) show effects lasting 3–6 months post‑treatment in pooled analyses, though certainty varies
Cancer pain / supportive care SRs	Systematic reviews find limited but suggestive evidence for symptom benefits (pain, nausea, fatigue) in cancer patients; trial sizes small and quality variable
Coding / Experimental use note	Acupuncture point injection when reported with standard injection CPTs (20550‑20553) is considered experimental/unproven

Definitions

Acupuncture point injection therapy: Procedure where pharmaceuticals or biological products are injected into acupuncture points; considered experimental/investigational/unproven by this policy.

Functional Outcome Measures (FOM): Standardized tests/measures used to quantify baseline and changes in function; when used should demonstrate Minimal Clinically Important Difference (MCID) from baseline through periodic reassessments.

CIPN: Chemotherapy-induced peripheral neuropathy.

AI-related joint pain: Aromatase inhibitor-induced arthralgia in breast cancer patients.

P6: Neiguan acupuncture point used for nausea/vomiting control.

Acupuncture Point Injection Therapy: Injection at acupuncture points; considered experimental/unproven in this policy due to insufficient peer-reviewed evidence of safety and efficacy.

Medicare Determinations

Name	Number	Type
Acupuncture	NCD 30.3	NCD
Acupuncture for Fibromyalgia	NCD 30.3.1	NCD
Acupuncture for Osteoarthritis	NCD 30.3.2	NCD
Decision Memo for Acupuncture for Chronic Low Back Pain	CAG-00452N	LCD

Revision History

2025-04-15effective

Policy effective date (Cigna Medical Coverage Policy - Therapy Services Acupuncture).

2026-04-15planned_reviewLatest

Next scheduled policy review date.

OpenPayer

Cigna Medical Coverage Policy- Therapy Services Acupuncture