Manual: IU Health Plans Department: Utilization Management Policy # UMDET001.2 Effective Date: 06/25/2020 Supersedes Policy # UMDET001.1 or Last update or issue date: 03/01/2019 Page(s) Including attachments: 6

Medicare Advantage X Commercial

Acupuncture Policy

I. Purpose

Indiana University Health Plans (IU Health Plans) considers clinical indications when making a medical necessity determination for .

II. Scope

All Utilization Management (UM) staff conducting physical and behavioral health UM review.

III. Exceptions A. Acupuncture is not considered medically necessary for any of the following:

1. Thermal stimulation acupuncture treatment is not covered. 2. Members under the age of 18 years.

Variation – Medicare Although acupuncture has been used for thousands of years in China and for decades in parts of Europe, it is a new agent of unknown use and efficacy in the United States. Even in those areas of the world where it has been widely used, its mechanism is not known. Three units of the National Institutes of Health, the National Institute of General Medical Sciences, National Institute of Neurological Diseases and Stroke, and Fogarty International Center have been designed to assess and identify specific opportunities and needs for research attending the use of acupuncture for surgical anesthesia and relief of chronic . 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 of §1862(a)(1) of the Act.

IV. Definitions

None

V. Policy Statements

A. IU Health Plans considers Acupuncture medically necessary for all of the following indications: 1. Members must be at least 18 years of age. 2. Acupuncture treatment must be ordered by a physician. 3. Provision of acupuncture is limited to physicians and appropriately credentialed and licensed acupuncturists. 4. Treating physician must document failure of other multimodal therapies. 5. Members with one of the following: a. Any of the following: 1) Migraine Headaches with all of the following: a) Symptoms experienced for 15 days or more per month and lasting four hours a day or longer b) Diagnosis with supporting medical testing or evaluations c) Duration, intensity, and frequency of the pain d) Failure of standard treatments for a period of six months or more 2) Chronic low back or neck pain with all of the following: a) Diagnosis with supporting medical testing or evaluations b) Duration, intensity, and frequency of pain c) Failure of standard treatments for a period of six months or more b. Acupuncture treatment for and is considered medically necessary for any of the following: 1) -induced with one of the following: a) History of high use of expensive and lacking effectiveness anti-emetics b) Certain chemotherapy regimens associated with high incidence of nausea and vomiting c) Evidence of vomiting not adequately controlled with multimodal pharmacologic prophylaxis d) Allergy or other contraindications to standard therapy 2) Post-operative with one of the following: a) History of high use of expensive and lacking effectiveness anti-emetics b) Certain chemotherapy regimens associated with high incidence of nausea and vomiting c) Evidence of vomiting not adequately controlled with multimodal pharmacologic prophylaxis d) Allergy or other contraindications to standard therapy 3) during pregnancy with one of the following: a) History of high use of expensive and lacking effectiveness anti-emetics b) Certain chemotherapy regimens associated with high incidence of nausea and vomiting c) Evidence of vomiting not adequately controlled with multimodal pharmacologic prophylaxis d) Allergy or other contraindications to standard therapy

Background It is estimated that approximately one million Americans utilize acupuncture procedures annually for relief from pain. Acupuncture is a procedure adapted from Chinese medical practice, in which the skin is pierced at specific body sites to induce anesthesia, improve certain symptoms such as chronic pain, nausea, vomiting, musculoskeletal and neurological conditions. The procedure consists of the insertion of very fine needles at acupoints.

Regulation of Acupuncture The U.S. Food and Drug Administration (FDA) regulates acupuncture needles and approves their use. A number of different brands of acupuncture needles have been approved via the 510(k) approval process; these needles must be sterile devices that meet the general specifications and criteria for a single-use needle.

Codes: CPT Codes Code Description 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the member 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the member, with re-insertion of needle(s).

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97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the member 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the member, with re-insertion of needle(s) ICD-10 Codes G43.001-G43.919 Migraine K91.0 Vomiting following gastrointestinal surgery K91.89 Other postprocedural complications and disorders of digestive system M17.0-M17.9 Osteoarthritis of knee M43.02 Spondylolysis, cervical region M53.3 Sacrococcygeal disorders, not elsewhere classified M54.15 Radiculopathy, thoracolumbar region M54.16 Radiculopathy, lumbar region M54.17 Radiculopathy, lumbosacral region M54.2 Cervicalgia M54.40-M54.42 Lumbago with sciatica M54.5 Low back pain M54.6 Pain in thoracic spine M54.89 Other dorsalgia M54.9 Dorsalgia, unspecified O21.0 Mild hyperemesis gravidarum O21.1 Hyperemesis gravidarum with metabolic disturbance O21.2 Late vomiting of pregnancy O21.8 Other vomiting complicating pregnancy O21.9 Vomiting of pregnancy, unspecified R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.2 Nausea with vomiting, unspecified S33.6XXS Sprain of sacroiliac joint, sequela T45.1X5A Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter T50.905A Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter T50.995A Adverse effect of other drugs, medicaments and biological substances, initial encounter

3 VI. Procedures

None

VII. References/Citations

1. Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee. Ann Int Med. 2004 Dec; 141(12):901-910. http://annals.org/article.aspx?articleid=718021 2. Carlsson C, Axemo P, Bodin A, et al. Manual acupuncture reduces hyperemesis gravidarum: a placebo-controlled, randomized, single-blind, crossover study. J Pain Symptom Manage. 2000 Oct; 20(4):273-279. http://ac.els-cdn.com/S0885392400001858/1-s2.0-S0885392400001858- main.pdf?_tid=7056384c-9daa-11e3-b178- 00000aacb361&acdnat=1393284290_37be1d89e8849bb61ba2dc2c597033a4 3. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) No 30.3 – Acupuncture. Effective date not posted: longstanding NCD. http://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=11&ncdver=1&DocID=30.3&SearchType=Advanced&bc=IAAAAAgAA AAAAA%3d%3d& 4. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) No. 30.3.1 - Acupuncture for Fibromyalgia. Effective: 04/16/04. http://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=283&ncdver=1&DocID=30.3.1&SearchType=Advanced&bc=IAAAAAg AAAAAAA%3d%3d& 5. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD_ No. 30.3.2 - Acupuncture for Osteoarthritis. Effective: 04/16/04. http://www.cms.gov/medicare- coverage-database/details/ncd- details.aspx?NCDId=284&ncdver=1&DocID=30.3.2&SearchType=Advanced&bc=IAAAAAg AAAAAAA%3d%3d& 6. Collins KB, Thomas DJ. Acupuncture and for the management of chemotherapy- induced nausea and vomiting. J Am Acad Nurse Prac. 2004 Feb; 16(2):76-80. http://www.ncbi.nlm.nih.gov/pubmed/?term=Collins+k+%5Bau%5D+AND+acupuncture+%5B ti%5D 7. Dundee JW, McMillan CM. Clinical uses of P6 acupuncture. Acupunct Electrother Res. 1990; 15(3-4):211-215. http://www.ncbi.nlm.nih.gov/pubmed/1982043 8. Dundee JW, Yang J. Prolongation of the antiemetic action of P6 acupuncture by acupressure in patients having cancer chemotherapy. J Royal Society of Medicine, 1990 Jun; 83(6):360-362. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292684/pdf/jrsocmed00135-0022.pdf 9. Dundee JW, Ghaly RG, Fitzpatrick KT, et al. Acupuncture prophylaxis of cancer chemotherapy-induced sickness. J R Soc Med. 1989 May; 82(5):268-271. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292129/pdf/jrsocmed00150-0024.pdf 10. Ezzo J, Vickers A, Richardson MA, et al. Acupuncture-point stimulation for chemotherapy- induced nausea and vomiting,” J Clin Oncol. 2005 Oct; 23(28):7188-7198. http://jco.ascopubs.org/content/23/28/7188.full.pdf+html 11. Gan T.J. Acupuncture reduces nausea and vomiting, pain after major breast surgery. In: ScienceDaily. Posted: September 22, 2004. Available at: http://www.sciencedaily.com/releases/2004/09/040922070424.htm

4 12. Hayes. Acupuncture and Acupressure for the Treatment of Nausea and Vomiting. Reviewed 05/21/14. 13. Linde K, Streng A, Juergens S, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA, 2005 May 4; 293(17):2118-2125. http://jama.jamanetwork.com/article.aspx?articleid=200822 14. McMillan C, Dundee JW, Abram WP. Enhancement of the anti-emetic action of ondansetron by transcutaneous electrical stimulation of the P6 anti-emetic point, in patients having highly emetic cytotoxic drugs. Br J Cancer, 1991 Nov; 64(5):971-972. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1977487/pdf/brjcancer00075-0179.pdf 15. National Institutes of Health (NIH) Consensus Conference: NIH Consensus Development Panel on Acupuncture (No authors listed). Acupuncture. Published in: JAMA. 1998; 280(17): 1518- 1524. http://jama.jamanetwork.com/article.aspx?articleid=188113 16. Neri I, Allais G, Schiapparelli P, et al. Acupuncture versus pharmacological approach to reduce hyperemesis gravidarum discomfort. Minerva Ginecol., 2005, Aug; 57(4):471-475. http://www.ncbi.nlm.nih.gov/pubmed/16170293 17. Raustia AM, Pohjola RT. Acupuncture compared with stomatognathic treatment for TMJ dysfunction. Part III: Effect of treatment on mobility. J Prosthet Dent. 1986 Nov; 56(5):616- 623. http://www.ncbi.nlm.nih.gov/pubmed?term=%22The+Journal+of+prosthetic+dentistry%22%5 BJour%5D+AND+56%5Bvolume%5D+AND+616%5Bpage%5D+AND+1986%5Bpdat%5D& cmd=detailssearch 18. Reindl TK, Geilen W, Hartmann R, et al. Acupuncture against chemotherapy-induced nausea and vomiting in pediatric oncology. Interim results of a multicenter crossover study. support care cancer. 2006 Feb; 14(2):172-176. http://download.springer.com/static/pdf/227/art%253A10.1007%252Fs00520-005-0846- z.pdf?auth66=1393453716_6a10609a74d43bc5da11693207053d0d&ext=.pdf 19. Rotchford JK. Overview: Adverse Events of Acupuncture. Medical Acupuncture, 1999-2000 Fall-Winter;11(2) 20. Shen J, Wenger N, Glaspy J, et al. Electroacupuncture for control of myeloablative chemotherapy-induced emesis: a randomized controlled trial. JAMA, 2000 Dec; 284(21):2755- 2761. http://jama.jamanetwork.com/article.aspx?articleid=193319 21. Streitberger K, Friedrich-Rust M, Bardenheuer H, et al. Effect of acupuncture compared with placebo-acupuncture at P6 as additional antiemetic prophylaxis in high-dose chemotherapy and autologous peripheral blood stem cell transplantation: A randomized controlled single-blind trial. Clin Cancer Res. 2003; 9(7):2538-2544. http://clincancerres.aacrjournals.org/content/9/7/2538.full.pdf+html 22. Stener-Victorin E, Kruse-Smidje C, Jung k. Comparison between electro-acupuncture and hydrotherapy, both in combination with patient education alone, on the symptomatic treatment of osteoarthritis of the hip. Clin J Pain, 2004 May; 20(3):179-185. http://ovidsp.tx.ovid.com/sp- 3.11.0a/ovidweb.cgi?WebLinkFrameset=1&S=FMHFFPPCDIDDEPNKNCMKMDMCCGJFA A00&returnUrl=ovidweb.cgi%3f%26Full%2bText%3dL%257cS.sh.22.23%257c0%257c00002 508-200405000- 00008%26S%3dFMHFFPPCDIDDEPNKNCMKMDMCCGJFAA00&directlink=http%3a%2f %2fgraphics.tx.ovid.com%2fovftpdfs%2fFPDDNCMCMDNKDI00%2ffs046%2fovft%2flive% 2fgv023%2f00002508%2f00002508-200405000- 00008.pdf&filename=Comparison+Between+Electro- Acupuncture+and+Hydrotherapy%2c+Both+in+Combination+With+Patient+Education+and+P atient+Education+Alone%2c+on+the+Symptomatic+Treatment+of+Osteoarthritis+of+the+Hip. &pdf_key=FPDDNCMCMDNKDI00&pdf_index=/fs046/ovft/live/gv023/00002508/00002508- 200405000-00008

5 23. Vickers AJ, Rees RW, Zollman CE, et al. Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial. BMJ, 2004 Mar; 328(7442):744. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC381326/pdf/bmj32800744.pdf 24. Witt C, Brinkhaus B, Jena S, et al. Acupuncture in patients with osteoarthritis of the knee: A randomized trial. Lancet, 2005 Jul; 366(9480):136-143. http://ac.els- cdn.com/S0140673605668717/1-s2.0-S0140673605668717-main.pdf?_tid=440a0152-9da4- 11e3-9ee4-00000aab0f26&acdnat=1393281639_7e3e86267eb0f3d1d51335433ba4d40e

VIII. Forms/Appendices

None

IX. Responsibility

Medical Director

This Policy is proprietary and confidential. No part of this Policy may be disclosed in any manner to a third party without the prior written consent of IU Health Plans, Inc.

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