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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyModa Health acupuncture Coverage & Prior Auth | Op…
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    CurrentModa HealthPolicy N/A

    Acupuncture — Coverage Criteria

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    Defines Moda Health coverage, criteria, and coding for acupuncture when listed as a covered benefit and administered by a legally qualified acupuncturist; applies to plan members whose benefit includes acupuncture. Specifies covered indications, limits, renewal requirements, and excluded indications and codes.

    Policy Summary
    PayerModa Health
    PolicyAcupuncture — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateDec 1, 2025
    Last ReviewNov 26, 2025
    Next Review DateNov 26, 2025
    Key ActionSubmit prior authorization with chart notes, prior treatments, and acupuncture evaluation/progress notes; medical necessity review is required after 20 visits for continued coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    10-20Requested course (over 2 months)

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    20Review threshold (visits)
    97810-97814Covered codes
    S8930Not covered code

    Coverage Criteria

    inv-01: Initial coverage criteria

    Covered when ALL of the following are met

    General coverage conditions: Needle acupuncture (manual or electroacupuncture) is covered when it is listed as a covered benefit and administered by a legally qualified acupuncturist practicing within the scope of his/her license.
    Covered indications: Indications include nausea and vomiting (postoperative, chemotherapy-induced, pregnancy), cancer-related pain, postoperative dental pain, temporomandibular disorders, as an adjunct to standard conservative therapy for chronic painful conditions (neck pain, low back pain, osteoarthritic knee or hip pain, migraine or tension headache), and tobacco cessation.Requested course is 10-20 treatments over two months.

    inv-02: Renewal Criteria

    Continued acupuncture treatment is appropriate when ALL of the following are met

    Renewal requirements: (a) Medical necessity review is performed after the 20th visit; (b) documentation of significant improvement in symptoms; (c) continued acupuncture is not requested for preventive, supportive, or maintenance care if the patient's symptoms are not improving or are regressing; (d) the treatment plan includes transition to a home exercise program as appropriate.

    inv-03: Conditions considered not medically necessary after 20 visits

    Not covered when ANY of the following apply after the first 20 visits

    Not covered conditions after 20 visits: Addiction; AIDS; Allergic Rhinitis; Asthma; Dermatologic conditions; Fibrotic Contractures; Glaucoma; Hypertension; Induction of Labor; Infertility; Lactation; Menstrual Cramps; Obesity; Psychiatric Diagnoses; Sensorineural Deafness; Stroke Rehabilitation; Tinnitus; Urinary Incontinence.

    List is not all-inclusive.

    Point injections (commonly referred to as Biopuncture) are expressly excluded for any indication and will not be covered. In addition, ambulatory auricular electrical stimulation devices (for example, P‑stim or E‑Pulse) that provide electrical stimulation of auricular acupuncture points are excluded from coverage.

    Acupuncture is not covered after the first 20 visits when used for the following conditions (list not all‑inclusive): Addiction; AIDS; Allergic rhinitis; Asthma; Dermatologic conditions; Fibrotic contractures; Glaucoma; Hypertension; Induction of labor; Infertility; Lactation; Menstrual cramps; Obesity; Psychiatric diagnoses; Sensorineural deafness; Stroke rehabilitation; Tinnitus; Urinary incontinence.

    Coding

    Covered CPT/HCPCS CodesCPTCovered
    97810Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with patient.
    97811Acupuncture, without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s).
    97813Acupuncture, with electrical stimulation, initial 15 minutes of personal one-on-one contact with patient.
    97814Acupuncture, with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s).
    Not Covered CodesHCPCSNot Covered
    S8930Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with patient.
    inv-08: Visit review threshold — Medical necessity review after the 20th visit
    ThresholdMedical necessity review is performed after the 20th visit
    Applies toContinued acupuncture treatment beyond initial course
    ReasonRequired to document significant improvement and appropriateness of continued care

    Provider Actions & Requirements

    Prior Authorization

    Prior authorization required for covered acupuncture services

    Prior authorization is required for covered needle acupuncture (manual or electroacupuncture) when the service is listed as a covered benefit and provided by a legally qualified acupuncturist practicing within the scope of license. Submit prior authorization for the requested course (typically 10–20 treatments over two months) for covered indications such as nausea/vomiting, cancer-related pain, postoperative dental pain, temporomandibular disorders, adjunctive therapy for chronic painful conditions (neck, low back, osteoarthritic knee/hip, migraine/tension headache), and tobacco cessation.

    • Covered CPT codes when criteria met: 97810, 97811, 97813, 97814 (see coding section).
    • Provider must be a legally qualified acupuncturist practicing within scope of license for services to be covered.
    Step Therapy

    Continuation requires medical necessity review and documented improvement after 20 visits

    Continued acupuncture beyond the 20th visit requires a medical necessity review and documentation that the patient has had significant improvement; the treatment plan should include transition to a home exercise program when appropriate.

    Background

    Acupuncture is an invasive therapy in which needle insertion (manual or with adjunctive electrical stimulation) is used at specific points to treat symptoms. Moda Health covers needle acupuncture when it is a listed benefit and provided by a legally qualified acupuncturist practicing within the scope of their license. The policy frames acupuncture primarily as an adjunct or targeted conservative treatment for specific indications (for example, nausea and vomiting related to surgery, chemotherapy or pregnancy; cancer‑related pain; postoperative dental pain; temporomandibular disorders; certain chronic painful conditions such as neck and low back pain, osteoarthritic knee or hip pain, and migraine or tension headache; and tobacco cessation). The typical requested course is 10–20 treatments over two months, and continuation beyond the initial course requires documentation of benefit and a medical necessity review.

    Definitions

    inv-15: Needle acupuncture definition — manual or electroacupuncture, insertion of needles at identifiable points
    DefinitionNeedle acupuncture (manual or electroacupuncture): insertion of needles at identifiable points close to the skin; may include electrical stimulation.
    Techniques includedManual needle insertion; electroacupuncture (electrical stimulation applied to inserted needles)
    Provider requirementMust be administered by a legally qualified acupuncturist practicing within scope of license for coverage to apply

    Conservative Treatment Requirements

    inv-16: Evidence of significant symptom improvement required for continuation after 20 visits

    Initial course 10-20 treatments over two months; continued treatment beyond 20 visits requires demonstration of significant symptom improvement

    Evidence required for continuation: An initial course of acupuncture is typically 10–20 treatments over two months. Continuation of treatment beyond 20 visits requires medical necessity review and documentation of significant improvement in symptoms to support further coverage.Initial course: 10-20 treatments over two months; Review threshold: after 20 visits.

    Transition to home exercise program should be included in the treatment plan as appropriate.

    Frequency Limits

    inv-17: Acupuncture (needle, manual or electroacupuncture) — 10-20 treatments
    Authorized course10-20 treatments over two months
    Indications (examples)Adjunct to standard conservative therapy for chronic painful conditions (neck pain, low back pain, osteoarthritic knee or hip pain, migraine or tension headache); nausea/vomiting; cancer-related pain; postoperative dental pain; temporomandibular disorders; tobacco cessation
    Provider requirementAdministered by a legally qualified acupuncturist practicing within scope of license
    inv-18: Continuation of acupuncture — medical necessity review after 20 visits
    Continuation requirementMedical necessity review after the 20th visit
    Documentation requiredDocumentation of significant improvement in symptoms; treatment plan includes transition to home exercise program as appropriate

    Not Covered

    This policy explicitly excludes point injections (Biopuncture) for any indication and ambulatory auricular electrical stimulation devices (for example, P‑stim and E‑Pulse). These exclusions mean claims for these therapies are not eligible for coverage under the acupuncture benefit described in this policy.

    Policy Summary
    PayerModa Health
    PolicyAcupuncture — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateDec 1, 2025
    Last ReviewNov 26, 2025
    Next Review DateNov 26, 2025
    Key ActionSubmit prior authorization with chart notes, prior treatments, and acupuncture evaluation/progress notes; medical necessity review is required after 20 visits for continued coverage.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & RequirementsBackgroundDefinitionsConservative Treatment RequirementsFrequency LimitsNot Covered
    • Continuation is not appropriate if care is preventive, supportive, or maintenance without symptom improvement.
    Documentation Required

    Prior authorization documentation: chart notes, diagnosis, prior modalities, evaluation and progress notes

    Prior authorization requests must include chart notes documenting the diagnosis, prior treatment modalities if applicable, and the original evaluation and progress notes from the acupuncture provider including a treatment plan for continued therapy.

    • Include diagnosis in chart notes.
    • Document prior treatments (if applicable).
    • Attach original evaluation and progress notes and treatment plan from the acupuncture provider.
    Denial Risk

    Denial risk for requests beyond 20 visits without review/documentation

    Requests for acupuncture beyond 20 visits submitted without the required medical necessity review and documentation of significant improvement may be denied.

    • Ensure documentation of symptom improvement is included with any request to continue treatment past 20 visits.
    Billing Rule

    Not covered: HCPCS S8930 will be denied

    Claims billed with HCPCS code S8930 (electrical stimulation of auricular acupuncture points) are not covered and will be denied.

    • Do not submit S8930 for reimbursement; it is excluded (auricular electrical stimulation, P-stim/E-Pulse).
    RestrictionContinued acupuncture not for preventive, supportive, or maintenance care if symptoms are not improving or regressing