Download National Medical Policy

yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts

Clinical trial wikipedia, lookup

Dental emergency wikipedia, lookup

Dry needling wikipedia, lookup

Acupuncture wikipedia, lookup

National Medical Policy
Policy Number:
Effective Date*:
October 2003
April 2006, April 2008, October 2009,
November 2009, March 2011, November
This National Medical Policy is subject to the terms in the
at the end of this document
The Centers for Medicare & Medicaid Services (CMS)
For Medicare Advantage members please refer to the following for coverage
guidelines first:
National Coverage Determination
National Coverage Manual Citation
Local Coverage Determination (LCD)
Acupuncture Nov 11
Reference/Website Link
Acupuncture for Fibromylagia:
Acupuncture for Osteoarthritis:
Non Covered Services; Physical Medicine and
Rehabilitation Policy:
Article (Local)
Use Health Net Policy
 Medicare NCDs and National Coverage Manuals apply to ALL Medicare members
in ALL regions.
 Medicare LCDs and Articles apply to members in specific regions. To access your
specific region, select the link provided under ―Reference/Website‖ and follow the
search instructions. Enter the topic and your specific state to find the coverage
determinations for your region
 If more than one source is checked, you need to access all sources as, on
occasion, an LCD or article contains additional coverage information than
contained in the NCD or National Coverage Manual.
 If there is no NCD, National Coverage Manual or region specific LCD/Article,
follow the Health Net Hierarchy of Medical Resources for guidance.
Current Policy Statement (Update November 2011 – A Medline search failed to
reveal any studies that would cause Health Net, Inc. to change its current position)
Please refer to the applicable benefit plan document to determine
benefit availability and the terms, conditions and limitations of
coverage for acupuncture
Health Net, Inc. considers acupuncture medically necessary for any of the following
Chronic low back pain; or
Chronic pain associated with osteoarthritis as adjuvant therapy; or
Nausea & vomiting associated post-operative procedures, chemotherapy or
pregnancy; or
Migraine headache.
Not Medically Necessary
Health Net, Inc. considers acupuncture investigational for all other indications,
including but not limited to any of the following conditions, because although studies
are still being done, there is inadequate scientific peer-reviewed research assessing
the safety, efficacy and long-term outcomes of acupuncture compared with other
modalities of treatment in these conditions:
Acute low back pain
Cancer-related dyspnea
Carpal tunnel syndrome
Chemotherapy-induced leukopenia
Acupuncture Nov 11
Chronic pain syndrome (e.g., RSD, facial pain)
Fetal breech presentation
Hot flashes
Induction of labor
Irritable bowel syndrome
Maintenance treatment, where the patient‘s pain symptoms are not improving
Menstrual cramps/dysmenorrhea
Myofascial pain
Neck pain/cervical spondylosis
Parkinson's disease
Peripheral arterial disease (e.g., intermittent claudication)
Post-herpetic neuralgia
Psychiatric disorders (e.g., depression)
Raynaud‘s disease pain
Sensorineural deafness
Shoulder pain (e.g., bursitis)
Stroke rehabilitation (e.g., dysphagia)
Tension headache
Urinary incontinence
Health Net, Inc. considers acupuncture not medically necessary for any of the
following indications, as the available scientifically based data fails to demonstrate
improved patient outcomes in the medical literature:
Fibrotic contractures
In lieu of traditional anesthesia
Painful neuropathies
Phantom leg pain
Rheumatoid arthritis
Smoking cessation
Tennis elbow/epicondylitis
Weight loss
Codes Related To This Policy
ICD-9 Codes
List may not be all-inclusive
Chronic tension-type headache
Migraine headache
Trigeminal neuralgia
643.00Excessive vomiting in pregnancy
Osteoarthritis, generalized
Acupuncture Nov 11
Osteoarthrosis, generalized
Lumbar disc protrusion
Synovitis and Tendonitis
Myalgia and myositis, unspecified
Nausea with vomiting [postoperative] [chemotherapy-induced]
Adverse effect of antineoplastic and immunosuppressive drugs
[chemotherapy-induced nausea and vomiting]
CPT Codes
Acupuncture one or more needles without electrical stimulation
(deleted 12/31/04)
Acupuncture one or more needles with electrical stimulation
(deleted 12/31/04)
Acupuncture, one or more needles, w/o electric stimulation; initial 15
minutes of personal one-one contact with the patient.
Acupuncture, one or more needles, w/o electric stimulation; each
additional 15 minutes of personal one-one contact with the patient
with re-insertion of needles.
Acupuncture, one or more needles, with electric stimulation; initial 15
minutes of personal one-one contact with the patient.
Acupuncture, one or more needles, with electric stimulation; each
additional 15 minutes of personal one-one contact with the patient,
with re-insertion of the needle(s).
Scientific Rationale – Update November 2009
Over the past several decades, the use of complementary and alternative medicine
(CAM) has increased in the general population. Between 1990 and 1997, the
percentage of American patients using alternative therapies grew considerably, from
34 to 42%. Acupuncture is among the CAM therapies most frequently recommended
by internists and family physicians and is currently practiced in over 140 hospitals in
the United States.
Professional Societies
(1997) National Institutes of Health consensus statement concluded that
acupuncture showed promise in adult postoperative and chemotherapy-induced
nausea and vomiting.
(1998) The National Institutes of Health (NIH) Office of Complementary and
Alternative Medicine Consensus Development Statement on acupuncture concluded
that acupuncture is effective in alleviating postoperative and chemotherapy nausea
in adults and may be effective for treating nausea in pregnancy. The NIH Consensus
Statement also concluded that the evidence was promising for the use of
acupuncture in some cases of pain management.
National Comprehensive Cancer Network guidelines recommend nonpharmacological
modalities such as acupuncture if pain scores remain at 4 or above on a 10-point
scale after re-evaluation and modification of pharmacological management. In the
absence of guidelines concerning when and how to incorporate complementary
Acupuncture Nov 11
therapies, decisions should be based on clinical judgment, patient preference, and
the risk/ benefit ratio.
(2003) The U.S. Department of Health and Human Services, Public Health Service,
Agency for Healthcare Research and Quality (AHRQ) recently performed a technology
assessment on Acupuncture for the Treatment of Fibromyalgia; it stated that ‗At this
time, therefore, there is insufficient evidence to conclude that acupuncture has
efficacy for the treatment of fibromyalgia.‘
(2007) The American College of Physicians (ACP) and American Pain Society
developed evidence-based clinical practice guidelines for diagnosing and treating low
back pain in the primary care setting. According to the guideline recommendations,
acupuncture is considered a moderately effective nonpharmacologic therapy for
treating chronic low back pain.
(2008) The American Academy of Orthopedic Surgeons has a section on
complementary and alternative therapy, are unable to recommend for or against the
use of acupuncture as an adjunctive therapy for pain relief in patients with
symptomatic OA of the knee. (Level of Evidence: I, Grade of Recommendation:
Chronic Low Back Pain
Deyo et al. (2009) performed a randomized controlled trial called (SPINE)
(Stimulating Points to Investigate Needling Efficacy). 638 adult patients were
included in this study, with patients randomly assigned to 4 groups:
Individualized needle acupuncture, involving a customized prescription for
acupuncture points.
Standardized needle acupuncture, using single prescription for acupuncture
points on back & backs of legs (i.e. generally effective for chronic LBP)
Simulated acupuncture on same standardized points, mimicking needle
acupuncture but instead of needle using toothpick in needle guide tube w/o
penetrating the skin
Standard medical care pts would have gotten. All pts in 3 acupuncture groups
(individualized, standardized, or simulated) were Rx 2x/wkx3wks, 1x/wkx4wks.
All patients in the three acupuncture groups (individualized, standardized, or
simulated) were treated 2x/weekx3weeks, 1x/weekx4weeks. At 8weeks, 6months,
& 1 year, back-related dysfunction was measured, and patients‘ symptoms were
noted. At 8 wks all 3 acupuncture groups were functioning substantially better,
while the group getting only usual care was functioning only slightly better.
Dysfunction scores improved significantly more for all 3 acupuncture groups than for
the usual care group. Benefits lasted for a year, although they waned over time.
Outcomes for groups that received the needle and simulated forms of acupuncture
did not differ significantly. So, although acupuncture effectively treated low back
pain, therapeutic benefit seemed to require neither acupuncture needle sites to
individual patient nor inserting needles into the skin. Simulated acupuncture,
without skin penetration, produced as much benefit as needle acupuncture. The
precise reason why simulated acupuncture relieves low back pain is unknown.
Future research is needed to delve deeper into what is evoking these positive
responses in simulated acupuncture.
Nausea and Vomitting
Acupuncture Nov 11
Since 1997, six studies have demonstrated efficacy for preventing postoperative
nausea and vomiting in children as well. A 2004 Cochrane review of 26 trials
involving 3347 children and adults showed that acupuncture with and without
electrical stimulation and acupressure are effective in decreasing the incidence of
postoperative nausea and vomiting in comparison with controls. When compared,
acupuncture and acupressure are equivalent to antiemetic drugs for preventing
vomiting but are actually better for preventing nausea.
Chronic Pain associated with Osteoarthritis of Knee
Miller et al. (2009) published the results of a randomized controlled clinical trial
(n=55) assessing the efficacy of acupuncture as an adjunct therapy to standard care
in a group of elderly patients with osteoarthritis of the knee. Primary outcome
measures were changes in Knee Society Score (KSS) and in KSS function and pain
ratings at therapy onset, after eight weeks and at 12 weeks. The authors noted
significant improvements in all scores for both groups at eight weeks and 12 weeks
compared with baseline. Acupuncture had a longer lasting effect—significant
differences between the intervention group and control group in the KSS was not
noticeable until after 12 weeks (eight weeks of therapy and one month follow-up).
Berman et al. (2004) completed a randomized controlled trial of 570 patients with
osteoarthritis of knee. Twenty-three true acupuncture sessions were done over 26
weeks. Controls received 6 (2 hour) sessions over 12 weeks or 23 sham acupuncture
sessions in 26 weeks. Patients in the true acupuncture group had >improvement in
WOMAC function scores than the sham acupuncture group at 8 weeks. Acupuncture
seems to provide improvement in function and pain relief as an adjunctive therapy
for osteoarthritis of knee when compared with credible sham acupuncture and
education control.
Migraine Headache
Linde et al. (2009) [Cochrane Database] completed a randomized study with two
reviewers. A post-randomization observation period of at least 8 weeks that
compared the clinical effects of an acupuncture intervention with a control (no
prophylactic treatment or routine care only), a sham acupuncture intervention or
another intervention in patients with migraine. Twenty-two trials with 4419
participants (mean 201, median 42, range 27 to 1715) met the inclusion criteria. Six
trials (including two large trials with 401 and 1715 patients) compared acupuncture
to no prophylactic treatment or routine care only. After 3 to 4 months patients
receiving acupuncture had higher response rates and fewer headaches. The only
study with long-term follow up saw no evidence that effects dissipated up to 9
months after cessation of treatment. Fourteen trials compared a 'true' acupuncture
intervention with a variety of sham interventions. Pooled analyses did not show a
statistically significant superiority for true acupuncture for any outcome in any of the
time windows, but the results of single trials varied considerably. Four trials
compared acupuncture to proven prophylactic drug treatment. Overall in these trials
acupuncture was associated with slightly better outcomes and fewer adverse effects
than prophylactic drug treatment. In the previous version of this review, evidence in
support of acupuncture for migraine prophylaxis was considered promising but
insufficient. Now, with 12 additional trials, there is consistent evidence that
acupuncture provides additional benefit to treatment of acute migraine attacks only
or to routine care. Available studies suggest that acupuncture is at least as effective
as, or possibly more effective than, prophylactic drug treatment, and has fewer
adverse effects. Acupuncture should be considered a treatment option for patients
willing to undergo this treatment.
Acupuncture Nov 11
NOTE: The following are general guidelines that may help to guide the frequency
and duration of acupuncture visits, depending on the severity of the various
conditions that the individual may have:
Stage of Condition
Chronic (Pain/Migraine)
Recurrent (Pain/Migraine)
3x week
3x week
3-5x week
4 weeks
4 weeks
3 weeks
Re-evaluate After
12 Treatments
12 Treatments
15 Treatments
Acupuncture in Lieu of Anesthesia
There are minimal studies done on acupuncture in lieu of anesthesia. Some
acupuncturists are doing this as part of their practice, however, there is no evidencebased peer-reviewed studies to support this practice.
CMS Centers for Medicare & Medicaid
NCD for Acupuncture (30.3)
Until the pending scientific assessment of the technique has been completed and its
efficacy has been established, Medicare reimbursement for acupuncture, as an
anesthetic or as an analgesic or for other therapeutic purposes, may not be made.
Accordingly, acupuncture is not considered reasonable and necessary within the
meaning §1862(a)(1) of the Act.
Fibromyalgia (NCD for Acupuncture for Fibromyalgia (30.3.1)
After careful reconsideration of its initial noncoverage determination for acupuncture,
CMS concludes that there is no convincing evidence for the use of acupuncture for
pain relief in patients with fibromyalgia. Study design flaws presently prohibit
assessing acupuncture‘s utility for improving health outcomes.
Osteoarthritis (NCD for Acupuncture for Osteoarthritis (30.3.2)
After careful reconsideration of its initial noncoverage determination for acupuncture,
CMS concludes that there is no convincing evidence for the use of acupuncture for
pain relief in patients with osteoarthritis. Study design flaws presently prohibit
assessing acupuncture‘s utility for improving health outcomes.
Scientific Rationale – Initial
Acupuncture is a traditional form of Chinese medical treatment that has been
practiced for over 3000 years. Acupuncture involves piercing the skin with needles at
specific body sites to induce anesthesia, to relieve pain, to alleviate withdrawal
symptoms of substance abusers, or to treat various non-painful disorders (e.g. to
relieve nausea/vomiting). In traditional acupuncture, the placement of needles into
the skin is dictated by the location of meridians. These meridians are thought to
mark patterns of energy flow throughout the human body. The technology has four
components - the acupuncture needle(s), the target location defined by traditional
Chinese medicine, the depth of insertion, and the stimulation of the inserted needle.
The FDA has approved acupuncture needles.
Electroacupuncture (i.e., transcutaneous electrical nerve stimulation (TENS)
acupuncture) is the practice of piercing specific body sites with needles that are
stimulated by an extremely low voltage of electricity.
Review History
Acupuncture Nov 11
October 16, 2003
April 2006
April 2008
September 2009
October 2009
November 2009
March 2011
November 2011
Medical Advisory Council
Update – no revisions
Update – no revisions. Codes updated.
Policy title changed to Acupuncture
Update. Policy had approved acupuncture for pain.
Added nausea, vomiting, and migraine headaches as
medically necessary. Added Medicare non-coverage.
Codes reviewed.
Revised policy with frequency of visits as advised from
committee members.
Update – no revisions
Update – no revisions
Patient Education Websites
1. National Center for Complementary and Alternative Medicine. Acupuncture.
Available at:
1. Fundación de la Artritis. Acupuntura. Acesso en:
This policy is based on the following evidence-based guidelines:
Lee A, Fan LTY. Stimulation of the wrist acupuncture point P6 for preventing
postoperative nausea and vomiting. Cochrane Database of Systematic Reviews,
2009, Issue 2.
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache.
Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007587.
American Academy of Orthopaedic Sugeons. Treatment of Osteoarthritis of the
knee (non-arthroplasty). Full Guideline. December 6, 2008. Available at:
Thomas LH, Cross S, Barrett J, et al. Treatment of urinary incontinence after
stroke in adults. Cochrane Database Syst Rev. 2008;(1): CD004462.
Bausewein C, Booth S, Gysels M, et al. Non-pharmacological interventions for
breathlessness in advanced stages of malignant and non-malignant diseases.
Cochrane Database Syst Rev. 2008;(2):CD005623.
Xie Y, Wang L, He J, Wu T. Acupuncture for dysphagia in acute stroke. Cochrane
Database Syst Rev. 2008;(3):CD006076.
Melchart D, Linde K, Fischer P, et al. Acupuncture for idiopathic headache.
Cochrane Database Systematic Reviews. The Cochrane Library, 2001 Issue 2.
2007. Updated April 15, 2008.
References – Update November 2011
Aranha MF, Alves MC, Bérzin F, Gavião MB. Efficacy of electroacupuncture for
myofascial pain in the upper trapezius muscle: a case series. Rev Bras Fisioter.
2011 Oct 14. pii: S1413-35552011005000022.
Cameron ID, Wang E, Sindhusake D. A Randomized Trial Comparing
Acupuncture and Simulated Acupuncture, for Sub-acute and Chronic Whiplash.
Spine (Phila Pa 1976). 2011 Apr 7.
Chen M, Shi XY, Xu B, et al. Clinical observation on acupotomy for treatment of
simple obesity. Zhongguo Zhen Jiu. 2011 Jun;31(6):539-42
Acupuncture Nov 11
Huang DM, Huang GY, Lu FE, et al. Acupuncture for infertility: is it an effective
therapy? Chin J Integr Med. 2011 May;17(5):386-95
Johansson K, Bergström A, Schröder K, Foldevi M. Subacromial corticosteroid
injection or acupuncture with home exercises when treating patients with
subacromial impingement in primary care--a randomized clinical trial. Fam
Pract. 2011 Aug;28(4):355-65
Kim DI, Jeong JC, Kim KH, et al. Acupuncture for hot flushes in perimenopausal
and postmenopausal women: a randomised, sham-controlled trial. Acupunct
Med. 2011 Jun 8
Kumnerddee W, Kaewtong A. Efficacy of acupuncture versus night splinting for
carpal tunnel syndrome: a randomized clinical trial. J Med Assoc Thai. 2010
Liu W, Yang G, Zhao XJ, et al. Impact of acupuncture on 24 h intraocular
pressure of glaucoma. Zhongguo Zhen Jiu. 2011 Jun;31(6):518-20
Mackenzie IZ, Xu J, Cusick C, Midwinter-Morten H, et al. Acupuncture for pain
relief during induced labour in nulliparae: a randomised controlled study. BJOG.
2011 Mar;118(4):440-7. doi: 10.1111/j.1471-0528.2010.02825.x
O'Sullivan EM, Higginson IJ. Clinical effectiveness and safety of acupuncture in
the treatment of irradiation-induced xerostomia in patients with head and neck
cancer: a systematic review. Acupunct Med. 2010 Dec;28(4):191-9
Shi ZM, Zhu YS, Wang QX, Lei MN. Comparative study on irritable bowel
syndrome treated with acupuncture and western medicine. Zhongguo Zhen Jiu.
2011 Jul;31(7):607-9
Sim H, Shin BC, Lee MS, et al. Acupuncture for carpal tunnel syndrome: a
systematic review of randomized controlled trials. Pain. 2011 Mar;12(3):30714.
Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for
pain management in labour. Cochrane Database Syst Rev. 2011 Jul
Smith CA, Crowther CA, Petrucco O, et al. Acupuncture to treat primary
dysmenorrhea in women: a randomized controlled trial. Evid Based Complement
Alternat Med. 2011;2011:612464
Smith CA, Ussher JM, Perz J, et al. The Effect of Acupuncture on Psychosocial
Outcomes for Women Experiencing Infertility: A Pilot Randomized Controlled
Trial. J. Altern Complement Med. 2011 Oct 6
Su JT, Zhou QH, Li R, et al. Immediate analgesic effect of wrist-ankle
acupuncture for acute lumbago: a randomized controlled trial. Zhongguo Zhen
Jiu. 2010 Aug;30(8):617-22
Sun MY, Hsieh CL, Cheng YY, et al. The therapeutic effects of acupuncture on
patients with chronic neck myofascial pain syndrome: a single-blind randomized
controlled trial. Am J Chin Med. 2010;38(5):849-59.
Takayama S, Seki T, Nakazawa T, et al. Short-term effects of acupuncture on
open-angle glaucoma in retrobulbar circulation: additional therapy to standard
medication. Evid Based Complement Alternat Med. 2011;2011:157090
Tong J, Chen JX, Zhang ZQ, et al. Clinical observation on simple obesity treated
by acupuncture. Zhongguo Zhen Jiu. 2011 Aug;31(8):697-701
Ursini T, Tontodonati M, Manzoli L, et al. Acupuncture for the treatment of
severe acute pain in herpes zoster: results of a nested, open-label, randomized
trial in the VZV Pain Study. BMC Complement Altern Med. 2011 Jun 5;11:46
White AR, Rampes H, Liu JP, et al. Acupuncture and related interventions for
smoking cessation. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD000009
Wu F, Kang MF, Xiong P, Xiong J. Clinical randomized controlled trials of
treatment of neck-back myofascial pain syndrome by acupuncture of Ashi-points
Acupuncture Nov 11
combined with moxibustion of heat-sensitive points. Zhen Ci Yan Jiu. 2011
23. Yang CP, Wang NH, Li TC, et al. A randomized clinical trial of acupuncture
versus oral steroids for carpal tunnel syndrome: a long-term follow-up. Pain.
2011 Feb;12(2):272-9
24. Zhu X, Hamilton KD, McNicol ED. Acupuncture for pain in endometriosis.
Cochrane Database Syst Rev. 2011 Sep 7;9:CD007864
References – Updated March 2011
Coura LE, Manoel CH, Poffo R, et al. Randomised, controlled study of
preoperative eletroacupuncture for postoperative pain control after cardiac
surgery. Acupunct Med. 2011 Mar;29(1):16-20
Jung A, Shin BC, Lee MS, Sim H, Ernst E. Acupuncture for treating
temporomandibular joint disorders: A systematic review and meta-analysis of
randomized, sham-controlled trials. J Dent. 2011 Feb 25. [
Kumnerddee W, Kaewtong A. Efficacy of acupuncture versus night splinting for
carpal tunnel syndrome: a randomized clinical trial. J Med Assoc Thai. 2010
Dec;93(12): 1463-9.
Lee MS, Ernst E. Acupuncture for pain: An overview of Cochrane reviews. Chin
J Integr Med. 2011 Mar;17(3):187-9.
Lee SW, Liong ML, Yuen KH, et al. Validation of a sham acupuncture procedure
in a randomised, controlled clinical trial of chronic pelvic pain treatment.
Acupunct Med. 2011 Mar;29(1):40-6.
Liang Z, Zhu X, Yang X, Fu W, Lu A. Assessment of a traditional acupuncture
therapy for chronic neck pain: a pilot randomised controlled study.
Li HJ, Zhong BL, Fan YP, Hu HT. Acupuncture for post-stroke depression: a
randomized controlled trial. Zhongguo Zhen Jiu. 2011 Jan;31(1):3-6
Lin CW, Haas M, Maher CG, et al. Cost-effectiveness of guideline-endorsed
treatments for low back pain: a systematic review. Eur Spine J. 2011 Jan 13
Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in
adults. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD007753.
Smith CA, Zhu X, He L, Song J. Acupuncture for primary dysmenorrhoea.
Cochrane Database Syst Rev. 2011 Jan 19;(1):CD007854
Sunay D, Ozdiken M, Arslan H, et al. The effect of acupuncture on
postmenopausal symptoms and reproductive hormones: a sham controlled
clinical trial. Acupunct Med. 2011 Mar;29(1):27-31.
Yang CP, Wang NH, Li TC, et al. A randomized clinical trial of acupuncture
versus oral steroids for carpal tunnel syndrome: a long-term follow-up. J Pain.
2011 Feb;12(2):272-9.
Yeh ML, Chung YC, Chen KM, et al. Acupoint electrical stimulation reduces acute
postoperative pain in surgical patients with patient-controlled analgesia: a
randomized controlled study. Altern Ther Health Med. 2010 Nov-Dec;16(6):108.
References – Updated October 2009
Deyo RA, Khalsa PS, Avins AL, et al. Acupuncture eases chronic low back pain in
SPINE trial. Stimulating Points to Investigate Needling Efficacy, (SPINE). The
National Center for Complementary and Alternative Medicine (NCCAM), part of
the National Institutes of Health, funded the SPINE trial. 2009.
Miller E, Maimon Y, Rosenblatt Y, et al. Delayed Effect of Acupuncture Treatment
in OA of the Knee: A Blinded, Randomized, Controlled Trial. Evid Based
Complement Alternat Med. 2009 Jan 5.
Acupuncture Nov 11
Smith CA, Crowther CA, Collins CT, et al. Acupuncture to induce labor: A
randomized controlled trial. Obstet Gynecol. 2008;112(5):1067-1074.
Cheong YC, Hung Yu Ng E, et al. Acupuncture and assisted conception. Cochrane
Database Syst Rev. 2008;(4):CD006920.
El-Toukhy T, Sunkara SK, Khairy M, et al. A systematic review and metaanalysis of acupuncture in in vitro fertilisation. BJOG. 2008;115(10):1203-1213.
Ng EH, So WS, Gao J, et al. The role of acupuncture in the management of
subfertility. Fertil Steril. 2008;90(1):1-13.
Lam YC, Kum WF, Durairajan SS, et al. Efficacy and safety of acupuncture for
idiopathic Parkinson's disease: A systematic review. J Altern Complement Med.
Ben-Aharon I, Gafter-Gvili A, Paul M, et al. Interventions for alleviating cancerrelated dyspnea: A systematic review. J Clin Oncol. 2008;26(14):2396-2404.
Lee MS, Pittler MH, Shin BC, et al. Bee venom acupuncture for musculoskeletal
pain: A review. J Pain. 2008;9(4):289-297.
Roberts J, Huissoon A, Dretzke J, et al. A systematic review of the clinical
effectiveness of acupuncture for allergic rhinitis. BMC Complement Altern Med.
Facco E, Liguori A, Petti F, et al. Traditional acupuncture in migraine: A
controlled, randomized study. Headache. 2008;48(3):398-407
Alecrim-Andrade J, Maciel-Júnior JA, Carnè X, et al. Acupuncture in Migraine
Prevention: A Randomized Sham Controlled Study With 6-months Posttreatment
Follow-up. Clin J Pain. 2008 Feb;24(2):98-105.
Yuan J, Purepong N, Kerr DP, Park J, et al. Effectiveness of acupuncture for low
back pain: a systematic review. Spine. 2008 Nov 1;33(23):E887-900.
Sun Y, Gan TJ. Acupuncture for the management of chronic headache: a
systematic review. Anesth Analg. 2008 Dec;107(6):2038-47.
Selfe TK, Taylor AG. Acupuncture and osteoarthritis of the knee: a review of
randomized, controlled trials. Fam Community Health. 2008 Jul-Sep;31(3):24754.
Jubb RW, Tukmachi ES, Jones PW, et al. A blinded randomised trial of
acupuncture (manual and electroacupuncture) compared with a non-penetrating
sham for the symptoms of osteoarthritis of the knee. Acupunct Med. 2008
Hurwitz EL, Carragee EJ, van der V, et al. Bone and Joint Decade 2000-2010
Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain:
noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task
Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15;33(4
Michelfelder AJ. Acupuncture for Headaches and Acupuncture for Nausea and
Vomiting. Rakel: Integrative Medicine, 2nd ed. 2007 Saunders, An Imprint of
Berman BM, Lao L, Lange P, et al. Effectiveness of Acupuncture as Adjunctive
Therapy in Osteoarthritis of the Knee. A Randomized, Controlled Trial. Annals of
Internal Medicine. 21 December 2004 | Volume 141 Issue 12 | Pages 901-910.
Centers for Medicare & Medicaid Services (CMS). NCD for Acupuncture for
Fibromyalgia (30.3.1) Pub. 100-03. Effective 2004 Apr 16. Available at:
Centers for Medicare & Medicaid Services (CMS). Acupuncture for Osteoarthritis
National coverage determination (NCD) (30.3.2). Effective 2004 April 16.
Available at:
Acupuncture Nov 11
22. Centers for Medicare & Medicaid Services (CMS). NCD for Acupuncture (30.3).
Available at:
References – Updated April 2008
Lee SWH, Liong ML, Yuen KH, et al. Acupuncture versus Sham Acupuncture for
Chronic Prostatis/Chronic Pelvic Pain. The American Journal of Medicine. Volume
121, Issue I (January 2008)
EE CE, Manheimer E, Pirotta MV, et al. Acupuncture for Pelvic Pain and Back
MARCH 2008.
Cherkin DC, Sherman KJ, Hogeboom CJ, et al. Efficacy of acupuncture for
chronic low back pain: protocol for a randomized controlled trial. PubMed
2008 Feb 28;9(1):10.
Tam LS, Leung PC, Li TK, Zhang L, et al. Acupuncture in the treatment of
rheumatoid arthritis: a double blind controlled pilot study. BMC Complement
Altern Med. 2007 Nov 3;7:35.
Brinkhaus B, Witt CM, Jena S, et al. Physician and treatment characteristics in a
randomised multicentre trial of acupuncture in patients with osteoarthritis of the
knee. Complement Ther Med. 2007 Sep;15(3):180-9. Epub 2006 Jun 22.
Cassileth BR, Deng GE, Gomez JE, et al. Complementary therapies and
integrative oncology in lung cancer: ACCP evidence-based clinical practice
guidelines (2nd edition). Chest. 2007 Sep;132(3 Suppl):340S-354S.
References - Initial
1. Audette JF, Blinder RA. Curr Pain Headache Rep. 2003 Oct;7(5):395-401.
2. Berman BM, Swyers JP, Ezzo J. The Evidence for Acupuncture as a Treatment for
Rheumatologic Conditions. Rheumatic Disease Clinics of North America 2000 Feb;
26(1): 103-15.
3. Chen R, Nickel JC. Acupuncture ameliorates symptoms in men with chronic
prostatitis/chronic pelvic pain syndrome. Urology. 2003 Jun;61(6):1156-9
4. Cummings M. Referred knee pain treated with electroacupuncture to iliopsoas.
Acupunct Med. 2003 Jun;21(1-2):32-5.
5. Guerra J, Bassas E, Andres M, et al. Acupuncture for soft tissue shoulder
disorders: a series of 201 cases. Acupunct Med. 2003 Jun;21(1-2):18-22;
discussion 22
6. Meng CF, Wang D, Ngeow J, et al. Acupuncture for chronic low back pain in older
patients: a randomized, controlled trial. Rheumatology (Oxford). 2003 Jul 30
7. Rabinstein AA, Shulman LM. Acupuncture in clinical neurology. Neurolog. 2003
8. Sator-Katzenschlager SM, Szeles JC, Scharbert G, et al. Electrical stimulation of
auricular acupuncture points is more effective than conventional manual auricular
acupuncture in chronic cervical pain: a pilot study. Anesth Analg. 2003
9. Smith MJ, Tong HC, Werner RA, Haig AJ. Acupuncture analgesia and
electromyography. Arch Phys Med Rehabil. 2003 Sep;84(9):E1-2.
10. Usichenko TI, Ivashkivsky OI, Gizhko VV. Treatment of rheumatoid arthritis with
electromagnetic millimeter waves applied to acupuncture points--a randomized
double blind clinical study. Acupunct Electrother Res. 2003;28(1-2):11-8.
Acupuncture Nov 11
11. Yeung CK, Leung MC, Chow DH. The use of electro-acupuncture in conjunction
with exercise for the treatment of chronic low-back pain. J Altern Complement
Med. 2003 Aug;9(4):479-90.
Important Notice
General Purpose.
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering
plan benefits and determining whether a particular procedure, drug, service or supply is medically
necessary. The Policies are based upon a review of the available clinical information including clinical
outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device,
evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select
national health professional organizations. Coverage determinations are made on a case-by-case basis
and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract,
including medical necessity requirements. Health Net may use the Policies to determine whether under the
facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically
necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not
constitute coverage. The member's contract defines which procedure, drug, service or supply is covered,
excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current
criteria that have been approved by Health Net‘s National Medical Advisory Council (MAC). The clinical
criteria and medical policies provide guidelines for determining the medical necessity criteria for specific
procedures, equipment, and services. In order to be eligible, all services must be medically necessary and
otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all
cases, final benefit determinations are based on the applicable contract language. To the extent there are
any conflicts between medical policy guidelines and applicable contract language, the contract language
prevails. Medical policy is not intended to override the policy that defines the member‘s benefits, nor is it
intended to dictate to providers how to practice medicine.
Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined
by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for
prior notification. If there is a discrepancy between the policy effective date and legal mandates and
regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior
notice or posting on the website is required before a policy is deemed effective. For information regarding
the effective dates of Policies, contact your provider representative. The Policies do not include
definitions. All terms are defined by Health Net. For information regarding the definitions of terms used
in the Policies, contact your provider representative.
Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some
states, prior notice or website posting is required before an amendment is deemed effective.
No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to
members. Members should consult with their treating physician in connection with diagnosis and
treatment decisions.
No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service
or supply. Members and providers should refer to the Member contract to determine if exclusions,
limitations, and dollar caps apply to a particular procedure, drug, service or supply.
Policy Limitation: Member’s Contract Controls Coverage Determinations.
The determination of coverage for a particular procedure, drug, service or supply is not based upon the
Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the
member‘s contract, and requirements of applicable laws and regulations. The contract language contains
specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums,
eligibility, and other relevant terms and conditions of coverage. In the event the Member‘s contract (also
known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies,
the Member‘s contract shall govern. Coverage decisions are the result of the terms and conditions of the
Member‘s benefit contract. The Policies do not replace or amend the Member‘s contract. If there is a
discrepancy between the Policies and the Member‘s contract, the Member‘s contract shall govern.
Policy Limitation: Legal and Regulatory Mandates and Requirements.
Acupuncture Nov 11
The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable
legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal
mandates and regulatory requirements, the requirements of law and regulation shall govern.
Policy Limitations: Medicare and Medicaid.
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and
determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid
members shall not be construed to apply to any other Health Net plans and members. The Policies shall
not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.
Acupuncture Nov 11