CurrentMass General Brigham Health PlanPolicy 03

Acupuncture Services

Defines coverage, medical necessity criteria, provider types, visit limits, and variations for commercial, MassHealth ACO, and Medicare Advantage members receiving acupuncture primarily for pain management.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAcupuncture Services

Policy CodePolicy 03

Change TypeClarified/Added/Operational

Effective DateNov 1, 2024

Next Review Date

Key ActionObtain prior authorization for acupuncture when services exceed 20 visits (visits 21+) and document measurable goals, prior treatment response, and communication with the primary care physician.

SourceLink

POLICY UPDATE CHANGES

Removed references to MassHealth and replaced with MassHealth Variation language; added criteria from a customized InterQual subset.

Medicare Advantage coverage clarified: acupuncture is covered only for chronic low back pain and Medicare members are limited to 20 visits per calendar year for chronic lower back pain.

Added InterQual-based medical necessity criteria for acupuncture starting at visit 21.

20Medicare member visit limit per year

1-20MassHealth visits without prior auth

21+Auth required (commercial/MassHealth ACO)

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Coverage and Medical Necessity Criteria

Medical necessity for continued acupuncture (visit 21+)

Covered when ALL of the following are met (InterQual custom subset governs medical necessity):

InterQual-based medical necessity for acupuncture (visits 21+): 1) The member's benefit package includes coverage of acupuncture services; 2) There is a clearly identifiable need for further treatment due to a significant change in condition and/or a new diagnosis of a painful condition that necessitates a different plan of care on visit 21 compared to visit 20; 3) Medical record documentation includes the condition causing pain, history, physical exam, and response to medical and acupuncture treatments to date; 4) The treating provider has established defined, measurable goals and the number of treatments necessary to reach those goals; 5) There is demonstrated communication about the plan of care between the acupuncturist and the primary care physician; 6) The member is expected to significantly benefit from the treatment within a defined period of time.visits > 20

Full criteria accessible via the plan's InterQual custom subset.

Medicare Advantage coverage

Medicare Advantage coverage stance:

Medicare Advantage NCDs: Mass General Brigham Health Plan follows CMS guidance for Medicare Advantage members. Acupuncture is covered only for chronic low back pain per Medicare NCDs (including NCD 30.3.3).20 visits/year

Coverage determinations for Medicare Advantage members are based on applicable NCDs, LCDs, and Medicare manual guidance.

Acupuncture is covered for the pain indications specified elsewhere in this policy. However, the policy explicitly excludes acupuncture when used for conditions other than the listed pain indications. Examples of excluded indications include acute lower back pain and irritable bowel syndrome. The policy also excludes acupuncture for any condition where the literature is limited and the intervention is considered experimental or investigational. Additionally, services that do not meet the policy's definition of acupuncture are not covered.

The policy identifies maintenance acupuncture as not medically necessary. It also lists acupuncture for conditions with limited supporting literature as experimental/investigational and therefore not medically necessary. For requests to continue services when treatment goals have not been met, documentation must describe progress toward goals, barriers affecting goal attainment, the plan to address those barriers, and the anticipated additional number of visits needed.

Coding and Visit Limits

Commercial and MassHealth Acupuncture CPT codes (informational)CPT

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; 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; with re-insertion of needle(s).

Medicare visit limit for chronic low back pain

Medicare visit limit for chronic low back pain20 visits per calendar year

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for acupuncture visits beyond 20 for Commercial and Qualified Health Plans and for MassHealth members when requesting visits 21 and beyond. Medicare Advantage: N/A. No notification or authorization is required for visits 1–20 for MassHealth; refer to individual commercial plan materials for details on when no prior authorization applies.

Visits 21 and beyond require prior authorization for Commercial and Qualified Health Plans
MassHealth: no prior authorization required for visits 1–20; prior authorization required for visits 21 and beyond
Medicare Advantage: N/A

Documentation Required

Continuation Requirements

For continuation/extension requests (visits beyond 20), the treating provider must demonstrate ongoing medical necessity by documenting progress toward established, measurable goals. If goals have not been met, the request must describe progress to date, identify barriers affecting goal attainment, outline interventions or changes to the plan of care to address those barriers, and state the anticipated number of additional visits needed to achieve the goals.

Background and Context

Acupuncture is described in the policy as a complementary treatment for pain that may be used in lieu of or alongside other therapies. Medical necessity for ongoing acupuncture beyond initial visits is evaluated within a conventional medical necessity framework: continuation requires measurable goals, documentation of prior response to treatment, and a plan demonstrating expected benefit. For continued services when goals are not yet met, the plan requires submission of progress toward goals, identified barriers, and a plan with an anticipated number of additional visits.

Definitions

Definition of Acupuncture

DefinitionThe insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, with or without electrical stimulation, and with or without application of heat to the needles or skin

Conservative Treatment and Prior Therapy Requirements

Demonstrate prior treatment response and measurable goals before authorization for visits 21+

Before authorization is granted for visits 21 and beyond, the following prior treatment response and measurable-goal documentation must be provided:

Prior treatments and response: Medical record documentation demonstrates prior medical and acupuncture treatments to date and the member's documented response to those treatments.

Measurable goals and expected benefit: The treating provider has defined measurable treatment goals, specified the number of treatments necessary to reach those goals, and documented that the member is expected to significantly benefit within a defined period.

Care coordination: There is demonstrated communication about the plan of care between the acupuncturist and the member's primary care physician, including plans to address barriers if goals are not being met.

Frequency and Visit Limits

Acupuncture for chronic low back pain (Medicare Advantage members)

Medicare Advantage numeric limit20 visits per calendar year for chronic low back pain

Imaging Requirements

Note

No imaging requirement

Imaging is not required for initial coverage or continuation of acupuncture services.

The policy states imaging_required = no for acupuncture.

Services Not Covered

Not covered indications include acute lower back pain and irritable bowel syndrome. The policy also lists as not covered any condition for which the literature is limited and acupuncture is considered experimental or investigational, maintenance acupuncture, and services that do not meet the policy’s definition of acupuncture.