Claim Payment Policy

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Title:

Acupuncture

Policy #:

12.00.01c

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Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified. In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service. For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the Company's coverage and reimbursement position for acupuncture.

For information on policies related to this topic, refer to the Cross References Table in this policy.

Description

According to the American Academy of Medical Acupuncture (AAMA), acupuncture is a therapeutic and/or preventive medical procedure performed by the insertion of one or more specially manufactured solid metallic needles into a specific location(s) on the body. The intent is to stimulate acupuncture points, with or without subsequent manual manipulation. Acupuncture has been used to induce anesthesia, relieve pain, alleviate withdrawal symptoms of addiction, and treat asthma and other disorders. According to traditional Chinese medical theory, with acupuncture, the placement of metallic needles into the skin is dictated by the location of meridians, which are thought to mark patterns of energy flow throughout the body. Acupuncture has the following four components:

The acupuncture needle(s) The target location The depth of insertion The stimulation of the inserted needle(s)

Policy

Acupuncture is a benefit contract exclusion for all Company products and groups, with the exception of New Jersey’s Small Employer Health (SEH) Group, where it is excluded except when used “as a substitute for other forms of anesthesia." For all other products, acupuncture is not covered and not eligible for reimbursement. When acupuncture is elected as a group option, coverage is dictated by the terms of the rider purchased by the group. Therefore, individual benefits must be verified, as coverage could vary between groups and products.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION
Subject to the terms and conditions of the applicable benefit contract, acupuncture is, generally, a benefit contract exclusion for all products of the Company.

MEDICARE This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

References

Centers for Medicare and Medicaid Services (CMS). Medicare National Coverage Determinations Manual. 30.3: Acupuncture. [CMS Web site]. 10/03/03. Available at: http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed March 20, 2009. Company Benefit Contracts. Highmark Medicare Services. Local Coverage Determination (LCD). L27540: Trigger point injections. [Highmark Medicare Services Web site]. 12/12/08. Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27540-r4.html. Accessed March 20, 2009.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	97810, 97811, 97813, 97814
ICD Procedure	N/A
ICD Diagnosis	N/A
HCPCS Level II	N/A
Revenue Codes	374: Anesthesia-acupuncture 2101: Alternative therapy-acupuncture

Cross References

Version Effective Date: 07/28/2005