ModifiedPHC CaliforniaPolicy N/A

Acupuncture

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This guideline governs when acupuncture is medically necessary, not medically necessary, or potentially eligible for coverage for members whose target condition meets specified clinical criteria.

Policy Summary

PayerPHC California

PolicyAcupuncture

Policy CodePolicy N/A

Change TypeModified

Effective Date08/22/2025

Next Review DateN/A

Key ActionFor continuing treatment, the requesting physician must document ongoing benefit from acupuncture and confirm that the individual continues to experience a qualifying condition.

SourceLink

POLICY UPDATE CHANGES

Added medically necessary indications for acupuncture and criteria for medically necessary continued therapy.

Removed pacemaker and automatic implantable cardioverter-defibrillator criteria.

Removed radiographic and other-cause exclusion criteria for osteoarthritis.

Revised the position on acupuncture for chronic hip and knee osteoarthritis and added it as medically necessary.

Removed ICD-9 codes and specified revenue codes from the coding section.

Clarified precedence of applicable law, contracts, and medical policy.

6Listed medically necessary target conditions

>12 weeksRequired persistence for selected indications

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ModifiedPHC CaliforniaPolicy N/A

Acupuncture

Customize your policy alerts

Sign up for all phccalifornia policy alerts

Know when phccalifornia releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This guideline governs when acupuncture is medically necessary, not medically necessary, or potentially eligible for coverage for members whose target condition meets specified clinical criteria.

Policy Summary

PayerPHC California

PolicyAcupuncture

Policy CodePolicy N/A

Change TypeModified

Effective Date08/22/2025

Next Review DateN/A

Key ActionFor continuing treatment, the requesting physician must document ongoing benefit from acupuncture and confirm that the individual continues to experience a qualifying condition.

SourceLink

POLICY UPDATE CHANGES

Added medically necessary indications for acupuncture and criteria for medically necessary continued therapy.

Removed pacemaker and automatic implantable cardioverter-defibrillator criteria.

Removed radiographic and other-cause exclusion criteria for osteoarthritis.

Revised the position on acupuncture for chronic hip and knee osteoarthritis and added it as medically necessary.

Removed ICD-9 codes and specified revenue codes from the coding section.

Clarified precedence of applicable law, contracts, and medical policy.

6Listed medically necessary target conditions

>12 weeksRequired persistence for selected indications

Medical Necessity Criteria

Initial acupuncture treatment

Acupuncture is medically necessary when the target of therapy is any one of the following conditions.

Qualifying treatment target

Nausea or vomiting associated with surgery, chemotherapy, or pregnancy.
Chronic osteoarthritis of the knee or hip that is significantly affecting daily activity.
Cancer pain.
Tension headache recurring for more than 12 weeks despite medication or behavioral therapy, such as biofeedback or relaxation therapy.>12 weeks
Migraine recurring for more than 12 weeks despite medication treatment.>12 weeks
Back or neck pain persisting for more than 12 weeks despite medication and physical therapy.>12 weeks

Continuing acupuncture treatment

Continuing acupuncture therapy is medically necessary when both criteria are met.

Continuation criteria

Ongoing qualifying condition: The individual continues to experience one or more of the conditions listed as medically necessary.
Ongoing benefit documented: The requesting physician documents ongoing benefit from the use of acupuncture.

Acupuncture is not medically necessary for indications other than the qualifying conditions specified in the coverage criteria.

Acupuncture using anesthesia, identified by procedure code 8E0H300, is not medically necessary.

Acupuncture is not medically necessary when the applicable clinical criteria are not met or when it is provided for any other indication.

The listed acupuncture procedure codes are not medically necessary when the coverage criteria are not met. Code 8E0H300 describes acupuncture using anesthesia and is designated not medically necessary.

Covered and Non-Covered Codes

When services may be Medically Necessary when criteria are metCPTCovered

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)

ICD-10 ProcedureICD-10Covered

8E0H30Z

Acupuncture

ICD-10 DiagnosisICD-10

All diagnoses

When services are Not Medically NecessaryICD-10Not Covered

8E0H300

Acupuncture using anesthesia

ICD-10 DiagnosisICD-10Not Covered

All diagnoses

Persistent tension headache or migraine

Tension headacheRecurring for more than 12 weeks despite medication or behavioral therapy, such as biofeedback or relaxation therapy.

MigraineRecurring for more than 12 weeks despite medication treatment.

Persistent back or neck pain

Back or neck painPersisting for more than 12 weeks despite medication and physical therapy.

Documentation and Denial Risks

Documentation Required

Document ongoing benefit for continuation

For continuing acupuncture therapy, the requesting physician must document ongoing benefit from acupuncture and confirm that the individual continues to experience one or more of the qualifying conditions.

Both requirements must be met for continuing treatment.
The individual must continue to experience one or more medically necessary qualifying conditions.
The requesting physician must document ongoing benefit from acupuncture.

Denial Risk

Verify qualifying indication before treatment

Acupuncture is not medically necessary when the clinical criteria are not met or when the treatment is provided for any other indication. Confirm that the patient’s condition meets one of the qualifying indications before requesting or providing treatment.

Clinical Background

Acupuncture stimulates specific points on the body with needles to treat health conditions. Treatment may include manual needle manipulation or electrical stimulation. The guideline addresses selected pain conditions, including chronic osteoarthritis, cancer pain, chronic tension headache, migraine, and back or neck pain; evidence varies by condition, and acupuncture may provide benefit for chronic low back or neck pain as a nonpharmacologic treatment option.

Key Definitions

Acupuncture

PracticeStimulating specific points on the body using needles to treat various health conditions.

Manual manipulationMay be incorporated into therapy.

Electrical stimulationMay be incorporated into therapy.

Chronic low back pain

DefinitionLow back pain lasting longer than 12 weeks is defined as chronic.

Required Prior Conservative Treatment

Persistent symptoms despite specified conservative treatments

For tension headache, migraine, and back or neck pain, document persistent symptoms despite the specified conservative treatment for more than 12 weeks.

Qualifying persistent-symptom pathway

Tension headache recurring for more than 12 weeks despite medication or behavioral therapy, such as biofeedback or relaxation therapy.>12 weeks
Migraine recurring for more than 12 weeks despite medication treatment.>12 weeks
Back or neck pain persisting for more than 12 weeks despite medication and physical therapy.>12 weeks

Not Covered Services

The following services are not covered as medically necessary: acupuncture using anesthesia; acupuncture when the specified clinical criteria are not met; and acupuncture for indications other than the qualifying conditions listed in the guideline.