CurrentWellCarePolicy CP.MP.92

Acupuncture coverage

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Defines medical necessity criteria, limitations, and coding guidance for needle acupuncture when it is a covered benefit under the health plan; applies to providers submitting claims for members covered by WellCare plans that adopt this policy.

Policy Summary

PayerWellCare

PolicyAcupuncture coverage

Policy CodePolicy CP.MP.92

Change TypeNo material changes noted

Effective Date

Next Review Date

Key ActionObtain prior authorization to demonstrate medical necessity per the policy criteria and support use of CPT codes 97810–97814.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 visitsinitial course

+6 visitscontinuation

≥15 days/monthmigraine threshold

97810–97814procedure codes

Medically Necessary Criteria and Limits

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CurrentWellCarePolicy CP.MP.92

Acupuncture coverage

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Policy Summary

PayerWellCare

PolicyAcupuncture coverage

Policy CodePolicy CP.MP.92

Change TypeNo material changes noted

Effective Date

Next Review Date

Key ActionObtain prior authorization to demonstrate medical necessity per the policy criteria and support use of CPT codes 97810–97814.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 visitsinitial course

+6 visitscontinuation

≥15 days/monthmigraine threshold

97810–97814procedure codes

Medically Necessary Criteria and Limits

Medically Necessary Criteria (needle acupuncture)

Covered when ALL of the following are met

Provider qualifications: Provided by a licensed acupuncturist or other appropriately licensed practitioner for whom acupuncture is within the practitioner's scope of practice and who has specific acupuncture training or credentialing

Permitted indications: Requested for one of: (1) postoperative or chemotherapy induced nausea and vomiting; (2) nausea and vomiting of pregnancy; (3) chronic low back, neck, or shoulder pain; (4) chronic migraines or moderate to severe chronic tension headaches occurring >= 15 days per month for more than three months; (5) pain from clinically diagnosed osteoarthritis of the knee or hip

Contraindications absent: None of the following contraindications: (1) severe neutropenia as seen after myelosuppressive chemotherapy; (2) insertion of acupuncture needles at sites of active infection or malignancy

Treatment Course and Continuation

Treatment frequency considered medically necessary

Initial course: An initial course of six visits over one month is considered medically necessary6 visits / 1 month

Continuation: If improvement occurs after the initial course, an additional six visits over two months is considered medically necessary to maintain improvement6 visits / 2 months

Use of acupuncture for indications other than those listed in the medically necessary criteria is not supported by current evidence and is not covered under this policy.

Available randomized trials and systematic reviews have evaluated acupuncture for multiple conditions, but evidence does not support coverage beyond the specified indications. Examples of conditions for which acupuncture is considered not supported by current evidence include, but are not limited to, arm pain, temporomandibular joint dysfunction, menstrual cramps, and fibromyalgia.

Procedure Codes

Covered CPT CodesCPTCovered

97810	Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97811	Acupuncture, one or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needle(s).
97813	Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97814	Acupuncture, one or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needle(s).

Authorization, Documentation, and Denials

Prior Authorization

Prior authorization required for acupuncture services

When acupuncture is a covered benefit, prior authorization is required to demonstrate medical necessity per the policy criteria and to support use of CPT codes 97810, 97811, 97813, and 97814.

Prior authorization must demonstrate the member meets the medically necessary criteria in the policy (provider qualifications, permitted indications, and absence of contraindications).
Prior authorization should indicate which CPT code(s) (97810–97814) will be billed.

Note

Provider action: confirm PA and practitioner qualifications

Obtain prior authorization and submit clinical evidence that aligns with the policy’s medically necessary criteria; confirm practitioner scope and credentialing.

Ensure the practitioner is a licensed acupuncturist or appropriately licensed practitioner for whom acupuncture is within scope and who has specific acupuncture training or credentialing.
Document the requested indication that matches one of the permitted indications in the policy.

Documentation Required

Required clinical documentation

Documentation must show the member meets the listed indication criteria and that acupuncture is provided by a licensed acupuncturist or appropriately licensed practitioner with specific acupuncture training/credentialing.

Include the clinical diagnosis supporting the indication (e.g., postoperative chemotherapy-induced nausea, chronic low back pain, chronic migraines meeting frequency criteria).
Document absence of contraindications (no severe neutropenia; no insertion at sites of active infection or malignancy).

Denial Risk

Denial risk for unsupported indications

Requests for acupuncture for indications not listed in the policy may be denied; current evidence does not support use for other conditions.

The policy lists permitted indications; use for other indications is considered not supported by current evidence and may be denied.
Examples of conditions not supported are noted in the policy’s not medically necessary/exclusion sections.

Prior Conservative Care Requirements

Conservative treatment requirements

Policy does not specify prerequisite conservative therapies prior to acupuncture; conservative modalities and clinical judgment may inform treatment.

Conservative therapy prerequisites: No specific prerequisite conservative therapies are required prior to initiating acupuncture per this policy; clinical decision-making may consider prior use of noninvasive therapies as appropriate

Policy states that it does not specify prerequisite conservative therapies prior to acupuncture

Background

Acupuncture involves manual and/or electrical stimulation of thin, solid metallic needles inserted into the skin. It has been studied for many conditions; evidence is strongest for postoperative or chemotherapy-induced nausea and vomiting, some pregnancy-related nausea, chronic low back/neck/shoulder pain, certain headaches (including chronic migraine and frequent tension-type headache), and osteoarthritis—particularly knee osteoarthritis. Typical treatment schedules in trials vary, but the policy defines specific visit thresholds when acupuncture is a covered benefit.

Policy Summary

PayerWellCare

PolicyAcupuncture coverage

Policy CodePolicy CP.MP.92

Change TypeNo material changes noted

Effective Date

Next Review Date

Key ActionObtain prior authorization to demonstrate medical necessity per the policy criteria and support use of CPT codes 97810–97814.

SourceLink

On This Page

Acupuncture coverage

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Medically Necessary Criteria and Limits

Acupuncture coverage

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Medically Necessary Criteria and Limits

Procedure Codes

Authorization, Documentation, and Denials

Prior Conservative Care Requirements

Visit Limits and Frequency

Imaging and Testing Requirements

Definitions

Background

Not Covered / Exclusions