New acupuncture benefit for Medicare Advantage members with chronic low back pain

July 8, 2020

On January 21, 2020, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare would begin to cover acupuncture treatment for chronic low back pain. In accordance with CMS, Independence is offering this benefit to our Medicare Advantage members.

Acupuncture (manual or with electrical stimulation) for chronic low back pain of up to 12 sessions in a 90-day period is considered medically necessary and, therefore, covered when all of the following criteria are met:

  • The individual has chronic low back pain lasting 12 weeks or longer.
  • The chronic low back pain is nonspecific, in that it has no identifiable systemic cause (e.g., not associated with metastatic, inflammatory, infectious disease).
  • The chronic low back pain is not associated with surgery.
  • The chronic low back pain is not associated with pregnancy.

Coverage details

When medically necessary, Medicare Advantage members are eligible for the following acupuncture benefits:

  • up to 12 sessions in a 90-day period
  • additional eight sessions covered for individuals demonstrating improvement
  • no more than 20 acupuncture treatments annually

Treatment will be discontinued after the initial 12 visits if the individual is not improving or if the individual is regressing.

Independence does not cover acupuncture that is not used to treat chronic low back pain. We follow Medicare’s guidance and do not cover any type of acupuncture, whether manual or with electrical stimulation (including dry needling), that is used for indications other than chronic low back pain.

Treatment requirements

Providers who render acupuncture services must comply with the following requirements:

  • Physicians: Physicians may furnish acupuncture in accordance with applicable state requirements.
  • Non-physicians: Physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel must meet applicable state requirements in order to provide acupuncture treatment to Medicare beneficiaries. They must also have:
    • A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine; and
    • Current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e., Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel performing acupuncture must also be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by CMS regulations.

Learn more

Additional information, including the applicable codes to use for billing acupuncture services, can be found in Medicare Advantage Policy #MA12.004a: Acupuncture, which was posted on our Medical Policy Portal on July 7, 2020, and went into effect January 21, 2020.

For more information on the CMS announcement, please visit their website.