ModifiedFallon Community Health Plan IncPolicy N/A

Acupuncture Services Payment Policy

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This policy governs coverage, prior authorization, provider qualifications, reimbursement, billing, and coding for outpatient acupuncture services for eligible Fallon Health members across applicable product lines.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyAcupuncture Services Payment Policy

Policy CodePolicy N/A

Change TypeModified

Effective DateDecember 1, 2026

Last ReviewOct 1, 2026

Next Review DateN/A

Key ActionDo not apply this policy to acupuncture services rendered at community health centers; route those services to the Plan's Community Health Center payment policy.

SourceLink

POLICY UPDATE CHANGES

The policy was revised to clarify that it does not apply to acupuncture services rendered at community health centers and to remove related coverage and reimbursement language.

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ModifiedFallon Community Health Plan IncPolicy N/A

Acupuncture Services Payment Policy

Customize your policy alerts

Sign up for all fallon_community_health_plan_inc policy alerts

Know when fallon_community_health_plan_inc releases new policies or updates existing guidance.

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Policy Summary

PayerFallon Community Health Plan Inc

PolicyAcupuncture Services Payment Policy

Policy CodePolicy N/A

Change TypeModified

Effective DateDecember 1, 2026

Last ReviewOct 1, 2026

Next Review DateN/A

Key ActionDo not apply this policy to acupuncture services rendered at community health centers; route those services to the Plan's Community Health Center payment policy.

SourceLink

POLICY UPDATE CHANGES

The policy was revised to clarify that it does not apply to acupuncture services rendered at community health centers and to remove related coverage and reimbursement language.

MassHealth ACO sessions without prior authorization

20Fallon Medicare Plus annual treatment limit

12 visits/90 daysInitial Medicare Plus benefit

8Additional Medicare Plus sessions with improvement

20NaviCare sessions without prior authorization

4 sessionsMassHealth ACO reassessment point

Plan-Specific Coverage Criteria

MassHealth ACO pain treatment

MassHealth ACO acupuncture for treatment of pain is covered when the applicable requirements are met.

Coverage requirements
- The service is medically necessary acupuncture for the treatment of pain.
- The applicable annual session limit is observed.Up to 20 sessions per calendar year without prior authorization; additional sessions require prior authorization
- Eligible provider
  - The service is furnished by a physician, qualifying midlevel practitioner, or qualifying acupuncturist licensed to practice acupuncture under 243 CMR 5.00.
    Acupuncturists may provide covered services for dates of service on or after January 21, 2022.
Clinical response
- The treatment plan addresses the member's condition and is reevaluated if no clinical benefit is appreciated after four sessions.Meaningful improvement required for further treatment
  Further treatment is not medically necessary without meaningful improvement in symptoms.

MassHealth ACO acupuncture detoxification

MassHealth ACO acupuncture detoxification is covered when the service meets the applicable program and facility requirements.

Acupuncture detoxification

The service is acupuncture detoxification as defined by MassHealth and is provided in a substance use disorder outpatient facility licensed by the Massachusetts Department of Public Health.Facility licensure requirements under 105 CMR 164.000
The benefit is administered by the Plan's behavioral health vendor.

MassHealth ACO anesthesia substitute

MassHealth ACO acupuncture as a substitute for conventional anesthesia is covered when all provider requirements are met.

Substitute for conventional anesthesia

The service is acupuncture used as a substitute for conventional anesthesia and is furnished by an anesthesiologist or certified registered nurse anesthetist licensed to practice acupuncture in Massachusetts under 243 CMR 5.00.
Coverage is pursuant to MassHealth Physician Manual 130 CMR 433.454(E).

Fallon Medicare Plus chronic low back pain

Fallon Medicare Plus covers acupuncture for chronic low back pain when all clinical criteria are met.

Chronic low back pain criteria

The pain lasts 12 weeks or longer; is nonspecific with no identifiable systemic cause; is not associated with surgery; and is not associated with pregnancy.12 weeks or longer
All listed chronic low back pain characteristics are required.

Treatment response and limits

The initial course does not exceed 12 visits in 90 days.Up to 12 visits in 90 days
Additional sessions are limited to members demonstrating improvement.Up to 8 additional sessions with prior authorization

NaviCare acupuncture

NaviCare covers medically necessary acupuncture under its annual and authorization limits.

The service is medically necessary acupuncture for any diagnosis, including electrical stimulation, infrared, or ultrasound services.
The service is within the applicable annual limit or has prior authorization for additional visits.Up to 20 sessions per year without prior authorization; additional visits require prior authorization
The acupuncture benefit is administered by the Plan's delegated vendor.

Summit ElderCare and Weinberg PACE

PACE coverage requires interdisciplinary approval.

PACE acupuncture services

The acupuncture service is approved by the member's Interdisciplinary Team.Approval required before service except emergency and out-of-area urgently needed care
PACE may provide additional medically necessary care beyond Medicare and Medicaid benefits when approved by the team.

Place of Service

This policy applies to acupuncture services provided in an outpatient setting.

Outpatient place of service

Acupuncture services must be provided in an outpatient setting for this policy to apply.

Acupuncture is not covered for Community Care members.

For Fallon Medicare Plus, acupuncture, including dry needling, is not covered for conditions other than chronic low back pain.

Do not report CPT 97810, 97811, 97813, or 97814 in conjunction with CPT 20560 or 20561. When acupuncture and dry needling are both performed, report only the acupuncture code(s).

Electrical stimulation, such as CPT 97032, is not separately reported when it is included in acupuncture services CPT 97813 or 97814.

Acupuncture needles are inherent to the acupuncture service and are not separately billable.

This payment policy does not apply to acupuncture services rendered at community health centers. Those services are addressed under the Plan's Community Health Center payment policy.

Further MassHealth ACO acupuncture treatment is not medically necessary when the member does not demonstrate meaningful improvement in symptoms. If no clinical benefit is appreciated after four sessions, the treatment plan must be reevaluated.

Fallon Medicare Plus acupuncture treatment must be discontinued if the member is not improving or is regressing.

Coding and Billing Rules

Dry needlingCPT

20560	Needle insertion without injection into 1 or 2 distinct muscles during a single session.
20561	Needle insertion without injection into 3 or more distinct muscles during a single session.

Acupuncture servicesCPT

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
98811	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).
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.

MassHealth acupuncturist office visitsCPT

99202	Office visit code referenced for one MassHealth acupuncturist office visit per member every four weeks.
99212	Office visit code referenced for one MassHealth acupuncturist office visit per member every four weeks.

Evaluation and management modifierModifier

25	Modifier 25 appended to a separately identifiable evaluation and management or office visit service.

Electrical stimulation billing restrictionCPTNot Covered

97032

Electrical stimulation; not reported separately when electrical stimulation is included in acupuncture services 97813 or 97814.

Acupuncture ServicesCPT

20560	Needle insertion without injection into 1 or 2 distinct muscles during a single session.
20561	Needle insertion without injection into 3 or more distinct muscles during a single session.
97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
98811	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).
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.

Medicare Plus Chronic Low Back Pain Duration

Qualifying duration12 weeks or longer

Clinical characteristicsNonspecific pain with no identifiable systemic cause, including no metastatic, inflammatory, or infectious disease

Additional requirementsNot associated with surgery and not associated with pregnancy

Acupuncture Time Increment

Reporting increment15 minutes

Required contact

Provider Actions and Payment Safeguards

Prior Authorization

MassHealth ACO Additional Sessions

For MassHealth ACO members, provide up to 20 medically necessary acupuncture sessions for pain per calendar year without prior authorization. Request prior authorization from Fallon Health for additional medically necessary sessions when the member’s condition, treatment, or diagnosis changes, and submit supporting documentation.

Prior Authorization

Medicare Plus Continuation Benefit

For Fallon Medicare Plus members, provide up to 12 medically necessary acupuncture sessions for chronic low back pain, with up to 8 additional sessions for members demonstrating improvement, subject to the 20-session annual maximum. The policy states that prior authorization is not required for the additional 8 sessions.

Prior Authorization

NaviCare Additional Visits

For NaviCare members, provide up to 20 medically necessary acupuncture sessions per calendar year without prior authorization. Additional medically necessary visits require prior authorization; although the benefit is administered by the delegated vendor, requests are reviewed by Fallon Health.

Policy Background

This policy addresses outpatient acupuncture services, including dry needling in specified Fallon Medicare Plus coverage, for pain-related conditions and other product-specific indications. Coverage, authorization, provider, documentation, reimbursement, and coding requirements vary by product. Fallon Medicare Plus limits covered acupuncture and dry needling to qualifying chronic low back pain; related billing rules include reporting services in 15-minute increments of personal face-to-face contact and observing applicable code-reporting restrictions.

Key Definitions

Chronic Low Back Pain

DurationPain lasting 12 weeks or longer

EtiologyNonspecific pain with no identifiable systemic cause, including no metastatic, inflammatory, or infectious disease

Exclusions from the definitionPain is not associated with surgery or pregnancy

Midlevel Practitioner

Certified nurse practitionerIncluded as a midlevel practitioner

Certified nurse midwife or certified registered nurse anesthetistIncluded as a midlevel practitioner

Other qualifying practitioners

Visit and Treatment Limits

MassHealth ACO Acupuncture for Treatment of Pain

Annual sessions without prior authorizationUp to 20 medically necessary acupuncture sessions for treatment of pain per calendar year

Additional sessionsAdditional medically necessary sessions may be covered with prior authorization

Authorization submissionSubmit the prior authorization request and supporting documentation to Fallon Health

Fallon Medicare Plus Chronic Low Back Pain

Initial visits12 sessions of medically necessary acupuncture in 90 days

Additional visits8 additional sessions for members demonstrating improvement; prior authorization is not required

Non-Covered Services and Indications

Acupuncture is not covered for Community Care members. For Fallon Medicare Plus, acupuncture or dry needling is not covered for conditions other than chronic low back pain.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyAcupuncture Services Payment Policy

Policy CodePolicy N/A

Change TypeModified

Effective DateDecember 1, 2026

Last ReviewOct 1, 2026

Next Review DateN/A

Key ActionDo not apply this policy to acupuncture services rendered at community health centers; route those services to the Plan's Community Health Center payment policy.

SourceLink

On This Page

Total treatment does not exceed 20 acupuncture treatments per calendar year.No more than 20 treatments per calendar year

Treatment must be discontinued if the member is not improving or is regressing.

Eligible furnishing provider

A physician, qualified nonphysician practitioner, or qualified auxiliary personnel furnishing the service incident to an eligible practitioner may provide the service under applicable requirements.Applicable state requirements and, for auxiliary personnel, required education, licensure, and supervision
Acupuncturists are not eligible to bill Medicare directly.

Personal face-to-face contact with the patient

Time basisReport based on personal face-to-face contact, not the duration of acupuncture needle placement

MassHealth ACO Annual Session Limit

Annual limit without prior authorizationUp to 20 medically necessary acupuncture sessions per calendar year

ServiceAcupuncture for the treatment of pain

Additional sessionsAdditional medically necessary sessions may be covered with prior authorization

Medicare Plus Initial Visit Limit

Initial courseUp to 12 visits

Time period90 days

Covered conditionChronic low back pain meeting the policy definition

Medicare Plus Annual Treatment Limit

Annual maximumNo more than 20 acupuncture treatments per calendar year

Additional sessionsUp to 8 additional sessions may be covered for members demonstrating improvement

Prior authorization for additional sessionsNot required for the additional 8 sessions

Prior Authorization

PACE Interdisciplinary Approval

For Summit ElderCare PACE and Fallon Health Weinberg PACE members, obtain approval from the member’s Interdisciplinary Team before providing care or services. Only emergency care and out-of-area urgently needed care are exempt from this approval requirement.

Documentation Required

Submit Prior Authorization and Documentation

Submit MassHealth ACO and NaviCare prior authorization requests, together with supporting clinical documentation, to the designated Fallon Health review function. MassHealth ACO requests go to Fallon Health; NaviCare additional-visit requests go to Fallon Health Care Review.

Documentation Required

Send Treatment Reports to the PCP

Acupuncturists furnishing acupuncture services to MassHealth members must report treatment results to the member’s primary care provider in writing. An initial telephone report may be used, but a written report of the initial consultation and subsequent periodic reevaluations must follow.

Billing Rule

Link the Qualifying Diagnosis

For Fallon Medicare Plus professional claims, link the CMS-qualifying chronic low back pain diagnosis to the acupuncture service at the line level using the diagnosis-code pointer. For outpatient facility claims, report the qualifying diagnosis at the claim-header level.

Documentation Required

Document Face-to-Face Time

Report acupuncture services in 15-minute increments of personal, face-to-face contact with the patient—not based on the duration of needle placement. Use the applicable acupuncture code for each qualifying increment and do not separately report electrical stimulation when it is included in the acupuncture code.

Billing Rule

MassHealth Office Visit Limit

An acupuncturist eligible to submit claims for acupuncture services provided directly to MassHealth members may bill only one office visit—99202 or 99212—per member every four weeks. The office visit and acupuncture treatment may be billed on the same day when permitted by 130 CMR 447.413(B).

Unsupported block type: documentation

Note

Community Health Center Exclusion

Do not apply this policy to acupuncture services rendered at community health centers. Route coverage and reimbursement questions for those services to the Plan’s Community Health Center payment policy.

Denial Risk

Medicare Plus Non-Covered Indications

Under Fallon Medicare Plus, acupuncture—including dry needling—is covered for chronic low back pain meeting the policy definition. Acupuncture, including dry needling, for any condition other than chronic low back pain is not covered.

Denial Risk

Reevaluate When Improvement Is Absent

MassHealth ACO acupuncture for pain must address the member’s condition. If no clinical benefit is appreciated after four sessions, reevaluate the treatment plan; further treatment is not medically necessary when the member does not demonstrate meaningful improvement in symptoms.

Denial Risk

Discontinue for Failure to Improve

Discontinue Fallon Medicare Plus acupuncture treatment if the member is not improving or is regressing. Additional continuation sessions are supported only for members demonstrating improvement.

Prior Authorization

PACE Team Approval Required

With the exception of emergency care and out-of-area urgently needed care, all care and services provided to Summit ElderCare PACE and Fallon Health Weinberg PACE members must be approved by the member’s Interdisciplinary Team before delivery.

Denial Risk

Billing Compliance Review

Verify that charges are supported by the applicable policy, member benefit, provider contract, and medical record before billing. The Plan may conduct post-payment audits and retract overpayments when charges are noncompliant or unsupported.

Denial Risk

Avoid Unsupported Billing

The Plan routinely verifies that billed charges comply with the policy and are appropriately documented in the medical record. Noncompliant or unsupported claims may be denied or subject to post-payment audit and overpayment retraction.

Clinical nurse specialist, psychiatric clinical nurse specialist, or physician assistant

Acupuncture Detoxification

Regulatory definitionDefined in 130 CMR 418.02

Manual descriptionDescribed in the MassHealth Substance Use Disorder Treatment Manual at 130 CMR 418.406(D)(4)

Program contextAcupuncture detoxification is a MassHealth substance use disorder treatment service

Medicare Acupuncture Provider Status

CMS recognitionAcupuncturists are not currently recognized by CMS as Medicare providers

Direct billingAcupuncturists are not eligible to bill Medicare directly for acupuncture services

Permitted furnishing arrangementAcupuncturists may provide acupuncture as auxiliary personnel incident to a physician or qualified nonphysician practitioner service in certain settings

Annual maximumNo more than 20 acupuncture treatments per calendar year

NaviCare Acupuncture

Annual limit without prior authorizationUp to 20 medically necessary acupuncture sessions per calendar year

Additional visitsAdditional medically necessary sessions may be covered with prior authorization

Authorization pathwaySubmit requests and supporting documentation to Fallon Health Care Review; requests are reviewed by Fallon Health