Original Department: Medical Management 12/03/2008 Approval: Policy #: MM132 Last Approval: 12/22/2020 Complementary/Alternative Care (Acupuncture, Biofeedback, Chiropractic, Title: Hypnotherapy, Massage Therapy, Naturopathy) Approved By: UM Medical Subcommittee

Line(s) of Business WAH-IMC (HCA) BHSO Medicare Advantage (CMS) Medicare SNP (CMS) Cascade Select

REQUIRED DOCUMENTATION: Medical records including history, exam, relevant imaging reports, laboratory tests, diagnosis and treatment plan.

Details of any specific needs related to risk/trauma/cultural etc.

POLICY This policy pertains to CHPW Medicare Advantage, CHPW Apple Health Integrated Managed Care (AH- IMC) and CHNW Cascade Select lines of business.

BACKGROUND None.

DEFINITIONS Acupuncture: involves the insertion of very thin needles through the skin at strategic points on the body. A key component of traditional Chinese medicine, acupuncture is commonly used to treat pain, but is also used to treat other physical and behavioral health conditions Biofeedback: a training program designed to develop one’s ability to control the automatic nervous system Chiropractic Treatment: focuses on manipulation of the musculoskeletal system, particularly the spine Hypnotherapy: the use of hypnosis as treatment Massage Therapy: a treatment involving manipulation, methodical pressure, friction, and kneading of the body Naturopathy: a system of healing that is founded on the basic premise that the body has an inherent capacity to establish, maintain, and restore health. It focuses on the healing power of nature, in the form of nutritional supplements, medicinal plants, and on both physical and spiritual exercises

Complementary_Alternative_Care_(Acupuncture,_Biofeedback,_Chiropractic,_Hypnothera 1 of 7 py,_Massage_Therapy,_Naturopathy)_Clinical_Coverage_Criteria_-_MM132_MM132 DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF COMMUNITY HEALTH PLAN OF WASHINGTON.

INDICATIONS/CRITERIA Please refer to each product line’s certificate of coverage for benefit limitations and exclusions for these services.

ACUPUNCTURE: FOR CHPW MEDICARE MEMBERS: See appropriate benefit grid for coverage information.

An additional 8 visits for acupuncture (maximum of 20 visits or less in a year) are allowed for a diagnosis of chronic low back pain lasting for 12 weeks or more, if the initial acupuncture has been beneficial: National Coverage Determination: Acupuncture for Chronic Low Back Pain (cLBP): NCD 30.3.3

FOR CHPW AH-IMC MEMBERS: See MM173 Acupuncture Limit Extension for Apple Health and IMC (FIMC) and benefit grid. FOR CHNW CASCADE SELECT MEMBERS: 12 visits are covered without prior authorization and no limitation extensions are allowed.

BIOFEEDBACK:

FOR CHPW MEDICARE MEMBERS: Please refer to NCD 30.1: Link NCD 30.1

FOR CHPW AH-IMC MEMBERS AND FOR CHNW CASCADE SELECT MEMBERS: Biofeedback (for headache or pelvic floor rehabilitation) initial treatment requires all the following regarding diagnosis and treatment plan: • The diagnosis includes one of the following: o Tension or migraine headache AND pharmacologic treatment is inadequate or not indicated due to on or the following: • Pregnancy, attempted pregnancy, breastfeeding • Deficient stress-coping skills that contribute to headache • History of excessive use of analgesic medications • Insufficient response to pharmacologic treatment attempts • Patient prefers non-pharmacologic interventions o Chronic pelvic pain o Myofascial pelvic floor dysfunction (such as, dyspareunia, high-tone pelvic floor dysfunction) o Patient is pregnant and wants to avoid urinary or fecal incontinence o Pelvic organ prolapse o Stress, urge, overflow, or mixed urinary incontinence o Urinary incontinence after radical prostatectomy Complementary_Alternative_Care_(Acupuncture,_Biofeedback,_Chiropractic,_Hypnothera 2 of 7 py,_Massage_Therapy,_Naturopathy)_Clinical_Coverage_Criteria_-_MM132_MM132 DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF COMMUNITY HEALTH PLAN OF WASHINGTON.

• The treatment plan includes all of the following: o Goals of therapy o Description of planned interventions

Biofeedback continued therapy requires all the following: • Documentation of progress towards the goal • Goal is not yet met • Documentation of the patient’s participation with the treatment plan during all the following: o Treatment sessions o Home exercises CHIROPRACTIC CARE:

FOR CHPW MEDICARE MEMBERS: The criteria are found in the Medicare Benefit Policy Manual and Noridian Local Coverage Article and The Medicare Benefit Policy Manual Chapter 15 Section 30.5 states: “Under the Medicare program, Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.” Link to Noridian Healthcare Solutions, LLC Local Coverage Article: Billing and Coding: Chiropractor Services (A57914) Summary of the LCA: The following criteria are required: History must include: • Mechanism of injury, • Onset of symptoms, or exacerbation • Current symptoms including quality, intensity, frequency, duration

Physical exam must include: • Pain/tenderness evaluated in terms of location, quality and intensity; • Asymmetry/misalignment identified on a sectional or segmental level; • Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and • Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle and ligament.

Complementary_Alternative_Care_(Acupuncture,_Biofeedback,_Chiropractic,_Hypnothera 3 of 7 py,_Massage_Therapy,_Naturopathy)_Clinical_Coverage_Criteria_-_MM132_MM132 DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF COMMUNITY HEALTH PLAN OF WASHINGTON.

• Objective evaluation of treatment effectiveness (for subsequent visits), including both the following: o Improved functional ability (with details or with a rating scale such as Oswestry Disability Index) o Decreased pain (using a rating scale) or decreased opioid dose

Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the bone named. To demonstrate subluxation based on physical examination, two of the four criteria mentioned under physical examination are required, one of which must be asymmetry/misalignment or range of motion abnormality.

Treatment Plan must include the following: • Therapeutic modalities to effect cure or relief (patient education and exercise training). • The level of care that is recommended (the duration and frequency of visits). • Specific goals that are to be achieved with treatment. • Plan for objective evaluation of treatment effectiveness (for initial visit) • Dates of initial and subsequent treatments.

The maximum number of sessions that can be considered for extension at one time is 12 because the criteria must continue to be met for the service to be medically necessary.

FOR CHPW AH-IMC MEMBERS: For Adults: Chiropractic care is not covered for adults. For Children: • To be eligible, clients must be 20 years of age and younger and referred by a screening provider under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. • The following are not covered under the Chiropractic Services for Children: • Therapy modalities (such as light, heat, hydro, and physical) o any food supplements, medications, or drugs o any braces, cervical collars, or supplies • Chiropractic services are not covered if: o there is evidence of concomitant neurologic deficit or radiculopathy; or o the chiropractic care is being provided for preventive therapy; or o the chiropractic care is being provided for maintenance therapy o For specific condition criteria see MCG for Chiropractic Care

FOR CHNW CASCADE SELECT MEMBERS: 10 visits are covered without prior authorization and no limitation extensions are allowed. Complementary_Alternative_Care_(Acupuncture,_Biofeedback,_Chiropractic,_Hypnothera 4 of 7 py,_Massage_Therapy,_Naturopathy)_Clinical_Coverage_Criteria_-_MM132_MM132 DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF COMMUNITY HEALTH PLAN OF WASHINGTON.

HYPNOTHERAPY: Hypnotherapy is not a covered benefit for CHPW Medicare Advantage or CHPW AH-IMC or for CHNW Cascade Select Lines of Business.

MASSAGE THERAPY:

FOR CHPW MEDICARE MEMBERS: Services rendered by massage therapists are not covered under Medicare.

FOR CHPW AH-IMC MEMBERS: Massage and massage therapy are specific contract exclusions.

FOR CHNW CASCADE SELECT MEMBERS: Massage and massage therapy are not covered.

NATUROPATHY:

FOR CHPW MEDICARE MEMBERS: See appropriate benefit grid for coverage information.

FOR CHPW AH-IMC MEMBERS: Naturopaths are recognized Health Care Professionals under the Apple Health program and can function as primary care providers within the community health center (CHC) system.

FOR CHNW CASCADE SELECT MEMBERS: Naturopaths are recognized Health Care Professionals under the Apple Health program and can function as primary care providers within the community health center (CHC) system.

SPECIAL CONSIDERATIONS None.

LIMITATIONS/EXCLUSIONS Please refer to a product line’s certificate of coverage for benefit limitations and exclusions for these services:

PRODUCT LINE LINK TO CERTIFICATE OF COVERAGE CHPW Medicare Advantage https://medicare.chpw.org/chpw-washington- state-medicare-advantage-plans/all-medicare- plans-2020/

Complementary_Alternative_Care_(Acupuncture,_Biofeedback,_Chiropractic,_Hypnothera 5 of 7 py,_Massage_Therapy,_Naturopathy)_Clinical_Coverage_Criteria_-_MM132_MM132 DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF COMMUNITY HEALTH PLAN OF WASHINGTON.

CHPW Apple Health Integrated Managed Care https://www.chpw.org/for-members/benefits- and-coverage-imc/ CHNW Cascade Select

Citations & References CFR WAC WAC 246-836-210; WAC 284-43-5640 RCW Contract Citation WAH - IMC 1.121: Health Care Professional (definition) 1.212: Primary Care Provider (PCP) (definition) 17.1.30.2 Medical necessity reviews for non-covered services, EPSDT BHSO MA Medicare Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, Effective January 1, 2020. Cascade Select WAC 284-43-5642 Essential health benefit categories Other Requirements NCQA Elements UM1 References

Revision History Revision Date Revision Description Revision Made By 12/03/2008 Approval MMLT 12/08/2010 Approval MMLT 11/21/2011 Updated clinical references Kelly Force, LPN 12/14/2011 Approval MMLT 11/28/2012 Approval MMLT 01/10/2014 Approval - Updated references, benefit MMLT updates 03/13/2015 Approval. Updated benefits information to MMLT current lines of business. 03/01/2017 Updated Acupuncture and Naturopathy Cyndi Stilson, RN MA plan coverage. Updated links 03/01/2017 Approval MMLT 02/01/2018 Edited MCG references. LuAnn Chen, MD Changed type of CCC from UM to MM. Links updated. 02/26/2018 Approval MMLT 07/13/2018 Added documentation requirements for LuAnn Chen, MD Medicare Members to receive approval of Chiropractic therapy. LCD L34009 Complementary_Alternative_Care_(Acupuncture,_Biofeedback,_Chiropractic,_Hypnothera 6 of 7 py,_Massage_Therapy,_Naturopathy)_Clinical_Coverage_Criteria_-_MM132_MM132 DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF COMMUNITY HEALTH PLAN OF WASHINGTON.

07/24/2018 Approval UM Committee 06/03/2019 Checked and corrected links. Acupuncture LuAnn Chen, MD and Naturopathy: referred to benefit grid for coverage information. Referenced MM173 for Apple Health. Added criteria for biofeedback for headache and pelvic floor rehabilitation 07/05/2019 Approval UM Medical Subcommittee 02/12/2020 WAH-IMC and MA Contract Citations LuAnn Chen, MD updated 05/05/2020 Added definitions LuAnn Chen, MD 05/14/2020 Approval UM Medical Subcommittee 09/09/2020 Added criteria and citations for CHNW LuAnn Chen, MD Cascade Select. Added criteria for 8 additional acupuncture visits for Medicare members with chronic low back pain. 09/10/2020 Approval UM Medical Subcommittee 12/11/2020 Updated and summarized LCA for LuAnn Chen, MD Chiropractic services and included NCD related to maintenance therapy. 12/22/2020 Approval UM Medical Subcommittee

Complementary_Alternative_Care_(Acupuncture,_Biofeedback,_Chiropractic,_Hypnothera 7 of 7 py,_Massage_Therapy,_Naturopathy)_Clinical_Coverage_Criteria_-_MM132_MM132 DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF COMMUNITY HEALTH PLAN OF WASHINGTON.