CurrentHawaii Medical Service Association (HMSA)Policy Ce N07

Complementary Care Rider — Acupuncture and Therapeutic Massage

Supplemental rider to HMSA's medical plan that defines coverage, limits, eligibility, and administrative requirements for acupuncture and therapeutic massage services for members covered under HMSA's medical plan.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyComplementary Care Rider — Acupuncture and Therapeutic Massage

Policy CodePolicy Ce N07

Change TypeNo material change

Effective DateJanuary 2025

Next Review Date

Key ActionObtain utilization review approval for any course of treatment that exceeds five visits in a calendar year by submitting required medical records or forms.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12maximum visits per calendar year (combined acupuncture and therapeutic massage)

$20copayment per visit for participating providers

5utilization review triggered after

2contact / submission lines

Coverage Criteria — Acupuncture & Therapeutic Massage

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Covered Services — Acupuncture and Therapeutic Massage

Covered when services meet the rider definitions and are provided by a duly licensed provider within the scope:

Acupuncture Covered Services: Includes a new patient exam or an established patient exam for initial evaluation of a new condition or new episode to determine appropriateness of Acupuncture Services; established patient exams as needed to assess the need to initiate, continue, extend, or change a Course of Treatment (reevaluation may be performed during a subsequent office visit or separately — separate coinsurance applies if separate); follow-up office visits that include provision of Acupuncture Services and/or reevaluation; adjunctive therapies or modalities (e.g., acupressure, moxibustion, breathing techniques) only when provided during the same Course of Treatment and in support of Acupuncture Services. Exception: acupressure is included where needle insertion is contraindicated and evidence-based standards indicate acupressure is effective.

Each office visit/acupuncture treatment counts as one visit toward the Benefit Maximum. See acupuncture exclusions for limitations.

Therapeutic Massage Covered Services: Includes a new patient exam or an established patient exam for initial evaluation of a new condition or new episode to determine appropriateness of Therapeutic Massage Services; an established patient exam when needed to assess the need to initiate, continue, extend, or change a Course of Treatment (the established patient exam is only covered when used to determine appropriateness of Therapeutic Massage Services); therapeutic massage sessions that apply therapeutic massage techniques to musculoskeletal soft tissue in various combinations. Members under age 18 require parental participation.

Each office visit/therapeutic massage treatment counts as one visit toward the Benefit Maximum. See therapeutic massage exclusions for limitations.

Utilization Review Trigger

Covered services subject to utilization review when the following condition is met:

Trigger for review: A review of medical records is required after the fifth visit per calendar year for therapeutic massage services (utilization review responsibility lies with participating providers; for nonparticipating providers the member is responsible).>5 visits/year

The five-visit waiver applies to nonparticipating providers who work in the same office under the same tax identification number. Submit the Medical Records Cover Sheet or Clinical Information Summary Sheet with required clinical details; ASH Group will respond within one week of receipt of the completed form.

General exclusions applicable to the Complementary Care Rider include services specifically listed in the policy such as chiropractic services; services provided in excess of any benefit maximum; any service or supply not permitted by state law for the practitioner's scope of practice; and services provided for elective or maintenance care where the member has reached maximum therapeutic benefit. The policy also excludes hospitalization, surgery, anesthesia, manipulation under anesthesia, injections, hypnotherapy, certain diagnostic or adjunctive technologies (for example thermography, magnets, laser biostimulation), and many other items and services enumerated in the limitations section (see list for full details).

Acupuncture-specific exclusions include services and treatments for conditions other than Musculoskeletal and Related Disorders, Nausea, Pain or Pain Syndromes; treatments for asthma or addiction (e.g., nicotine addiction); radiology and laboratory services; adjunctive therapy not associated with acupuncture; acupuncture performed with reusable needles; and cupping. Therapeutic massage-specific exclusions include services for conditions other than covered musculoskeletal categories (Myofascial/Musculoskeletal Disorders, Musculoskeletal Functional Disorders, Pain Syndromes, or lymphedema), therapeutic massage delivered outside the terms of the benefit plan (including massage provided directly in conjunction with acupuncture when not permitted), and any adjunctive therapy whether or not associated with therapeutic massage.

Visit Limits and Coding Details

Visit Limit — Combined Acupuncture and Therapeutic Massage

Maximum visits per calendar yearNo more than 12 visits per calendar year (combined across acupuncture and therapeutic massage)

Applies to both provider typesLimit applies to services from Participating and Nonparticipating Providers (see Schedule of Benefits)

Counting visitsEach office visit/acupuncture treatment or therapeutic massage session counts as one visit toward the benefit maximum

Utilization Review Trigger

Utilization review triggerA review of medical records is required after the fifth visit per calendar year

Applies to therapeutic massageSpecifically called out for therapeutic massage services; applies to both Participating and Nonparticipating Providers

Responsibility for submissionFor Participating Providers the provider is responsible; for Nonparticipating Providers the member/provider is responsible for submission

Provider Requirements, Documentation & Utilization Review

Prior Authorization

Prior Authorization / Utilization Review Requirement — approval required for >5 visits

Prior authorization / utilization review is required when more than five visits per calendar year are requested. For participating providers, utilization review is the provider's responsibility; for nonparticipating providers, the member is responsible for initiating utilization review. Therapeutic massage requires medical record review after the fifth visit per calendar year. The five-visit waiver applies to all nonparticipating providers who work in the same office under the same tax identification number.

Prior authorization / utilization review required for >5 visits per calendar year
Participating providers: provider is responsible for utilization review
Nonparticipating providers: member is responsible for utilization review; five-visit waiver applies to providers sharing the same tax ID
Therapeutic massage: medical record review required after the 5th visit

Note

Post-5th-visit utilization review required — therapeutic massage

After the fifth visit in a calendar year for therapeutic massage, a review of medical records is required to continue coverage. Ensure medical records include the details requested on the Medical Records Cover Sheet or Clinical Information Summary Sheet to avoid delays.

Medical record review required after 5th visit per calendar year for therapeutic massage
Provide complete clinical documentation to support medical necessity

Documentation Required

Claims and Utilization Review Documentation Requirements

Providers and members must submit required forms and documentation. Use the Medical Records Cover Sheet or Clinical Information Summary Sheet (one per patient) available at www.ashcompanies.com and include the requested clinical details to ensure timely review.

Complete a Medical Records Cover Sheet or Clinical Information Summary Sheet (one per patient)
Include date(s) of service and services to be reviewed, patient age and gender, chief complaint, pain severity, mechanism/onset, and pertinent physical exam findings (at minimum inspection and palpation)
Include provider NPI and other identifying provider information

Documentation Required

Required documentation submission & ASH Group response

Send the completed Medical Records Cover Sheet and either the Clinical Information Summary Sheet or the pertinent medical records to ASH Group at the address or fax numbers provided. ASH Group will respond within one week of receipt of the completed form. Notification will be sent to the provider and will include peer-clinician contact information.

Mail: ASH Group, P.O. Box 509001, San Diego, CA 92150-9001
Fax: California fax (877) 427-4777; all other states fax (877) 304-2746
Claims mailing address: ASH Group, P.O. Box 509001, San Diego, CA 92150-9001
ASH Group will respond within one week of receipt of the completed form

Denial Risk

Incomplete Utilization Review Information — provide complete records to avoid non-approval

Incomplete utilization review information or missing documentation may result in non-approval for reimbursement or denial of the claim. To prevent denials, provide complete information on the required forms; incomplete documentation from nonparticipating providers may increase the risk of denial.

Without complete information, services may not be approved for reimbursement
Incomplete documentation may cause denial, especially for nonparticipating providers

Background — Scope of the Rider

This rider supplements HMSA's medical plan to cover two complementary therapies when delivered within the defined scope: Acupuncture Services for Musculoskeletal and Related Disorders, Nausea, and Pain conditions, and Therapeutic Massage Services for Myofascial/Musculoskeletal Disorders, Musculoskeletal Functional Disorders, Pain Syndromes, and lymphedema. Services are intended to treat signs and symptoms related to the nervous, muscular, and skeletal systems and related functional limitations.

Covered services count toward a combined maximum of visits and are subject to utilization review: each office visit or treatment session (acupuncture or therapeutic massage) counts as one visit toward the benefit maximum, and a medical record review is required after the fifth visit per calendar year for therapeutic massage (applies to both participating and nonparticipating providers as described in the Utilization Review section).

Definitions — Services and Course of Treatment

Acupuncture Services — Definition and Scope

DefinitionAcupuncture Services: stimulation of a point on or near the body surface by insertion/removal of single-use, sterilized, disposable needles and/or electrical stimulation (electroAcupuncture) to normalize physiological functions or treat Musculoskeletal and Related Disorders, Nausea, or Pain.

Scope — adjunctive modalitiesMay include adjunctive physiotherapy modalities and procedures provided during the same Course of Treatment and in support of Acupuncture Services.

Conditions treatedIntended for Musculoskeletal and Related Disorders, Nausea, and Pain conditions (includes postoperative, chemotherapy-related, and pregnancy-related nausea where appropriate).

Therapeutic Massage Services — Definition and Clinical Indications

DefinitionTherapeutic Massage Services: services provided for treatment of Myofascial/Musculoskeletal Disorders, Musculoskeletal Functional Disorders, Pain Syndromes, and/or lymphedema through physical actions primarily by hand.

Techniques includedMay include techniques such as compression, stroking, joint movement, friction, vibration, and percussion.

Intended clinical useUsed to treat musculoskeletal soft-tissue conditions and related functional limitations as defined under covered services.

Course of Treatment — Definition

DefinitionCourse of Treatment: a sequence or series of office visits directly related to a diagnosed disease state, illness, or injury and provided in conjunction with a defined clinical outcome.

Visit countingVisits that are part of the same Course of Treatment (for acupuncture or therapeutic massage) count toward the benefit maximum; each office visit/treatment counts as one visit.

PurposeEstablishes the expected series of visits tied to a diagnosis and intended clinical outcome for continuation or reassessment of care.