Complementary and Alternative Medicine, Including Acupuncture

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Medical Policy

Policy Number: OCA 3.194 Version Number: 18 Version Effective Date: 01/01/21

Product Applicability All Plan+ Products

Well Sense Health Plan Boston Medical Center HealthNet Plan Well Sense Health Plan MassHealth ACO MassHealth MCO Qualified Health Plans/ConnectorCare/Employer Choice Direct

Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options only if there are no criteria established for the specified service in Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options.

Policy Summary The Plan considers complementary and alternative medicine NOT to be medically necessary, except as specified in the member’s applicable benefit document. The Plan’s Medically Necessary medical policy, policy number OCA 3.14, specifies the definition of a medically necessary service by Plan product type.

Complementary and Alternative Medicine, Including Acupuncture

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. 1 of 19

Acupuncture is a covered service for a Plan member when the treatment is included in the member’s product-specific benefit documents as a covered service for the specified indication. Review the BMC HealthNet Plan member’s applicable benefit documents at www.bmchp.org (or at www.SeniorsGetMore.org for a Senior Care Options member) for the most up-to-date information on benefit coverage for acupuncture treatment and other types of complementary and alternative medicine.

When acupuncture is a covered service and used as an aid to a covered MassHealth member or Senior Care Options member who is withdrawing from dependence on substances or in recovery from addiction, requests for treatment must be submitted to Beacon Health Options directly for review and prior authorization approval. Beacon Health Options may be contacted at 1-888-217-3501 or at www.beaconhealthstrategies.com. Review the Medical Policy Statement section of this policy for the applicable prior authorization guidelines by Plan product for other treatment indications for acupuncture (i.e., indications NOT reviewed by Beacon Health Options) when acupuncture is a covered service for the member for the requested indication(s).

Description of Item or Service Acupuncture: The insertion of metal needles through the skin at certain points on the body, with or without herbs, with an electric current and/or heat to the needles or skin. Acupuncture may be used for pain relief or anesthesia (i.e., loss of sensitivity to pain), as an aid to persons who are withdrawing from dependence on substances or in recovery from addiction, or for other indications. Practiced in China and other Asian countries for thousands of years, acupuncture is one of the key components of traditional Chinese medicine.

Complementary or Alternative Medicine (CAM): A group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. Complementary medicine is used together with conventional medicine. Alternative medicine is used in place of conventional medicine. There are several different types of CAM that include but are not limited to the following examples:

1. Biologically-Based Practices: Techniques that utilize substances found in nature (e.g., aromatherapy). Some examples of these substances include botanical products, animal-derived products, herbal supplements, vitamins, minerals, probiotics, creams, essential oils, ointments, and/or dietary supplements.

2. Energy Medicine: Techniques that involve the use of energy fields. Some examples include Reiki, therapeutic touch, pulsed fields, magnetic fields, electromagnetic, and/or alternating- current or direct-current fields.

3. Manipulative and Body-Based Practices: Techniques that are used to manipulate or move one or more parts of the body. Some examples include massage (by a massage therapist), myotherapy, craniosacral therapy, hippotherapy, yoga, and/or reflexology. Complementary and Alternative Medicine, Including Acupuncture

4. Mind-Body Medicine: A variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some examples include biofeedback, hypnotherapy, meditation, prayer, mental healing, and/or therapies that use creative outlets such as art, music or dance.

5. Whole Medicine Systems: Medicine based on theory and practice. Some examples include homeopathic medicine, naturopathic medicine, and traditional Chinese medicine such as acupuncture and Ayurveda.

Medical Policy Statement The member’s product-specific benefit documents will determine coverage for complementary and alternative medicine services, including acupuncture and other types of complementary and alternative medicine, as specified below in items 1 through 3:

1. The Plan does NOT consider complementary and alternative medicine (CAM) services medically necessary for Plan members, except as covered in the member’s applicable benefit documents available at www.bmchp.org for a BMC HealthNet Plan member or at www.SeniorsGetMore.org for a Senior Care Options member.

2. There may be separate medical policies that address the treatment of specific conditions or procedures that supersede this policy. See the Plan’s Prior Authorization/Notification Requirements matrix available at www.bmchp.org for prior authorization guidelines by service type for BMC HealthNet Plan members, including Senior Care Options members. Review the Plan’s Biofeedback in an Outpatient Setting to Treat Incontinence or Constipation medical policy, policy number OCA 3.969, for applicable medical necessity criteria for biofeedback.

3. Prior authorization requirements for acupuncture are based on the treatment indication(s) and Plan product guidelines, as specified below in ONE (1) of the following items a through c:

a. Prior authorization is REQUIRED through Beacon Health Options (rather than the Plan) for acupuncture when it is a covered service for a MassHealth member or Senior Care Options member and used as an aid to a member who is withdrawing from dependence on substances or in recovery from addiction. The treating provider must contact Beacon Health Options directly at 1-888-217-3501 or at www.beaconhealthstrategies.com; OR

b. For MassHealth members, Plan prior authorization is NOT required for acupuncture for other covered indications (i.e., treatment indications NOT reviewed by Beacon Health Options, as stated above) such as pain relief or anesthesia (i.e., loss of sensitivity to pain) when the service is billed with a code included in the Applicable Coding section of this policy and acupuncture is a covered benefit for the member for the specified indication. Review the BMC HealthNet Plan member’s product-specific benefit documents available at Complementary and Alternative Medicine, Including Acupuncture

www.bmchp.org to determine if acupuncture is a covered service for the requested treatment indication(s).

c. For Senior Care Options members, Plan prior authorization is REQUIRED for acupuncture when used for other indications (i.e., treatment indications NOT reviewed by Beacon Health Options, as stated above) such as the treatment of chronic low back pain. The Plan utilizes clinical review criteria and coverage guidelines specified in the applicable national coverage determination (NCD) developed by the Centers for Medicare & Medicaid Services (CMS) to determine the medical necessity for the requested acupuncture sessions based on the treatment indication(s), provider type rendering the service, and frequency and duration of acupuncture treatment. Review the Senior Care Options member’s product-specific benefit documents available at www.SeniorsGetMore.org to determine if acupuncture is a covered service for the requested treatment indication(s).

Limitations The Plan considers complementary and alternative medicine NOT to be medically necessary, except as covered in the member’s applicable benefit documents available at www.bmchp.org for a BMC HealthNet Plan member (or at www.SeniorsGetMore.org for a Senior Care Options member). See the Plan’s Medically Necessary medical policy, policy number OCA 3.14, for the definition of a medically necessary service by Plan product type.

When acupuncture is a covered service and is used as an aid for the covered MassHealth member or Senior Care Option member who is withdrawing from dependence on substances or in recovery from addiction, requests for treatment must be submitted directly to Beacon Health Options for review and prior authorization approval. Beacon Health Options may be contacted at 1-888-217-3501 or at www.beaconhealthstrategies.com. Review the Medical Policy Statement section of this policy for the applicable prior authorization guidelines by Plan product for other treatment indications for acupuncture (i.e., indications NOT reviewed by Beacon Health Options) when acupuncture is a covered service for the member for the requested indication(s).

Definitions Dry Needling: A skilled intervention by which thin filiform needles are used to penetrate the skin and stimulate underlying trigger points, muscle, and connective tissues to manage neuromusculoskeletal pain and impaired movement. According to the American Physical Therapy Association (APTA), the treatment is a type of manual therapy used by physical therapists for intramuscular stimulation. Alternative treatments include stretching, massage, ischemic compression, laser therapy, heat acupressure, ultrasound, transcutaneous electrical nerve stimulation, biofeedback, and pharmacologic treatment. According to the American Association of Acupuncture and Oriental Medicine (AAAOM) and the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM), dry needling is a type of acupuncture.

Complementary and Alternative Medicine, Including Acupuncture

Integrative Medicine: Coordinating conventional and complementary medicine to manage an individual’s symptoms such as reducing pain and anxiety.

Applicable Coding The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Since the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service.

Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member. See Plan reimbursement policies for Plan billing guidelines.

This applicable code list includes complementary and alternative medicine (CAM) services with an assigned CPT or HCPCS code. See the Plan’s Reimbursement Policy - Chiropractic Services (Spinal Manipulation), policy number 4.114, available at www.bmchp.org for billing and reimbursement guidelines for chiropractic treatment for BMC HealthNet Plan members. Review the Plan’s medical policy, Physical Therapy in the Outpatient Setting, policy number OCA 3.54, rather than this policy for manual therapy administered by a physical therapist.

CPT Codes Description: Service is considered NOT medically necessary, except as specified in the member’s applicable benefit document 90880 Hypnotherapy

Plan note: Code is NOT payable for the Senior Care Options product. 97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

Complementary and Alternative Medicine, Including Acupuncture

97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

Plan notes: 1. When acupuncture is used as an aid for a MassHealth member or Senior Care Options member withdrawing from dependence on substances or in recovery from addiction, prior authorization is REQUIRED through Beacon Health Options (rather than the Plan). 2. For MassHealth members, Plan prior authorization is NOT required for acupuncture for other covered indications (i.e., treatment indications NOT reviewed by Beacon Health Options, as stated above) such as pain relief or anesthesia (i.e., loss of sensitivity to pain) when the service is billed with this applicable code and is a covered benefit for the member for the specified indication. 3. For Senior Care Options members, Plan prior authorization is REQUIRED for acupuncture when used for other indications (i.e., indications NOT reviewed by Beacon Health Options, as stated above) such as the treatment of chronic low back pain. The Plan utilizes clinical review criteria and coverage guidelines specified in the applicable national coverage determination (NCD) developed by the Centers for Medicare & Medicaid Services (CMS) to determine the medical necessity for the requested acupuncture sessions based on the treatment indication(s), provider type rendering the service, and frequency and duration of acupuncture treatment when acupuncture is a covered benefit for the member for the specified indication. 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with patient, with re-insertion of needle(s)

Complementary and Alternative Medicine, Including Acupuncture

low back pain. The Plan utilizes clinical review criteria and coverage guidelines specified in the applicable NCD developed by CMS to determine the medical necessity for the requested acupuncture sessions based on the treatment indication(s), provider type rendering the service, and frequency and duration of acupuncture treatment when acupuncture is a covered benefit for the member for the specified indication. 97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

Plan notes: 1. When acupuncture is used as an aid for a MassHealth member or Senior Care Options member withdrawing from dependence on substances or in recovery from addiction, prior authorization is REQUIRED through Beacon Health Options (rather than the Plan). 2. For MassHealth members, Plan prior authorization is NOT required for acupuncture for other covered indications (i.e., treatment indications NOT reviewed by Beacon Health Options, as stated above) such as pain relief or anesthesia (i.e., loss of sensitivity to pain) when the service is billed with this applicable code and is a covered benefit for the member for the specified indication. 3. For Senior Care Options members, Plan prior authorization is REQUIRED for acupuncture when used for other indications (i.e., indications NOT reviewed by Beacon Health Options, as stated above) such as the treatment of chronic low back pain. The Plan utilizes clinical review criteria and coverage guidelines specified in the applicable NCD developed by CMS to determine the medical necessity for the requested acupuncture sessions based on the treatment indication(s), provider type rendering the service, and frequency and duration of acupuncture treatment when acupuncture is a covered benefit for the member for the specified indication. 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)

Complementary and Alternative Medicine, Including Acupuncture

applicable code and is a covered benefit for the member for the specified indication. 3. For Senior Care Options members, Plan prior authorization is REQUIRED for acupuncture when used for other indications (i.e., indications NOT reviewed by Beacon Health Options, as stated above) such as the treatment of chronic low back pain. The Plan utilizes clinical review criteria and coverage guidelines specified in the applicable NCD developed by CMS to determine the medical necessity for the requested acupuncture sessions based on the treatment indication(s), provider type rendering the service, and frequency and duration of acupuncture treatment when acupuncture is a covered benefit for the member for the specified indication. HCPCS Codes Description: Service is considered NOT medically necessary, except as specified in the member’s applicable benefit document M0075 Cellular therapy

Plan note: Code is NOT payable for the Senior Care Options product. S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-to-one contact with patient

Plan notes: 1. When acupuncture is used as an aid for a member withdrawing from dependence on substances or in recovery from addiction, prior authorization is REQUIRED through Beacon Health Options. 2. Prior authorization is NOT required for acupuncture used for pain relief or anesthesia (i.e., loss of sensitivity to pain) when the service is billed with this applicable code and is a covered benefit for the member for the specified indication. S8940 Equestrian/hippotherapy, per session

Plan note: Code is NOT payable for the Senior Care Options product.

Clinical Background Information Complementary medicine generally refers to using a non-mainstream approach to treatment together with conventional medicine (also considered integrative medicine or integrative health care). Alternative medicine refers to using a non-mainstream approach to treatment in place of conventional medicine, which is less common.

Acupuncture has been studied for a wide range of pain conditions, such as postoperative dental pain, carpal tunnel syndrome, fibromyalgia, headache, low-back pain, menstrual cramps, myofascial pain, osteoarthritis, and tennis elbow. Acupuncture is generally considered safe when performed by a licensed practitioner using sterile needles. Relatively few complications from acupuncture have been

Complementary and Alternative Medicine, Including Acupuncture

reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.

At the time of the Plan’s most recent policy review, no clinical guidelines were found from the Centers for Medicare & Medicaid Services (CMS) specifically for complementary and alternative medicine (i.e., a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine). CMS decision memo CAG-00452N states that effective January 21, 2020 CMS covers acupuncture for the treatment of chronic low back pain provided by a qualified practitioner up to the maximum number of covered treatments within an established timeframe when low back pain lasts 12 weeks or longer, has no identifiable systemic cause, is not associated with surgery, and is not related to pregnancy. CMS has the following national coverage determinations (NCD) for acupuncture that state the treatment is not considered reasonable and necessary (other than the use specified above for chronic low back pain) because the efficacy for acupuncture has not been established for other indications: NCD for Acupuncture (30.3), NCD for Acupuncture for Fibromyalgia (30.3.1), and NCD for Acupuncture for Osteoarthritis (30.3.2). Verify the CMS benefit and medical necessity guidelines for acupuncture services for the requested treatment indication(s) in effect on the date of the prior authorization request, including the maximum number of covered visits within an established treatment timeframe. Determine if applicable CMS criteria are in effect for the specific type of complementary and alternative medicine and the indication for treatment in an NCD or local coverage determination (LCD) on the date of the prior authorization request for a Senior Care Options member.

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American Chronic Pain Association (ACPA). ACPA Resource Guide to Chronic Pain management, An Integrated Guide to Medical, Interventional, Behavioral Pharmacologic and Rehabilitation Therapies. Feinberg S (ed.) American Chronic Pain Association Inc., Rocklin, California. 2019. Accessed at: https://www.theacpa.org/wp-content/uploads/2019/02/ACPA_Resource_Guide_2019.pdf

American College of Chest Physicians (ACCP). Deng GE, Rausch SM, Jones LW, Gulati A, Kumar NB, Greenlee H, Pietanza MC, Cassileth BR. Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed: ACCP evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e420S-36S. doi: 10.1378/chest.12-2364. PMID: 23649450.

American College of Gastroenterology. Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013 Jan;108(1):18-37;quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13. PMID: 23147521.

Complementary and Alternative Medicine, Including Acupuncture

American College of Physicians (ACP). Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute and Chronic Low Back Pain: A Clinical Guideline from the ACP. Ann Intern Med. 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14. PMID: 28192789.

American Society of Anesthesiologists (ASA), American Society of Regional Anesthesia and Pain Medicine (ASRA). Rosenquist RW, Benzon HT, Connis RT, De Leon-Casasola OA, Glass D, Korevaar WC, Cynwyd B, Mekhail NA, Merrill DG, NIckinovich DG, Rathnmell JP, Nai-Mei Sang C, Simon DL; ASA Task Force on Chronic Pain Management. Practice guidelines for chronic pain management: an updated report by the ASA Task Force on Chronic Pain Management and the ASRA. Anesthesiology. 2010 Apr;112(4):810-33. doi: 10.1097/ALN.0b013e3181c43103. PMID: 20124882.

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Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Acupuncture (30.3). Effective Date Not Posted. Accessed at: https://www.cms.gov/medicare- coverage-database/details/ncd- details.aspx?NCDId=11&ncdver=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NC A%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Bo th&s=24&KeyWord=acupuncture&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=EA AAABAAAAAA&

Complementary and Alternative Medicine, Including Acupuncture

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Acupuncture for Fibromyalgia (30.3.1). 2004 Apr 16. Accessed at: https://www.cms.gov/medicare- coverage-database/details/ncd- details.aspx?NCDId=283&ncdver=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=N CA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=B oth&s=24&KeyWord=acupuncture&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=E AAAABAAAAAA&

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Acupuncture for Osteoarthritis (30.3.2). 2004 Apr 16. Accessed at: https://www.cms.gov/medicare- coverage-database/details/ncd- details.aspx?NCDId=284&ncdver=1&NCAId=84&IsPopup=y&bc=AAAAAAAAIAAA&

Centers for Medicare & Medicaid Services (CMS). Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N). 2020 Jan 21. Accessed at: https://www.cms.gov/medicare-coverage- database/details/nca-decision-memo.aspx?NCAId=295

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Grech D, Li Z, Morcillo P, Kalyoussef E, Kim DD, Bekker A, Ulloa L. Intraoperative Low-frequency Electroacupuncture under General Anesthesia Improves Postoperative Recovery in a Randomized Trial. J Acupunct Meridian Stud. 2016 Oct;9(5):234-41. doi: 10.1016/j.jams.2016.03.009. Epub 2016 Apr 4. PMID: 27776761.

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Complementary and Alternative Medicine, Including Acupuncture

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Lee S, Park J, Kim J, Kang JW, Choi DY, Park SJ, Nam D, Lee JD. Acupuncture for postoperative pain in laparoscopic surgery: a systematic review protocol. BMJ Open. 2014 Dec 23;4(12):e006750. doi: 10.1136/bmjopen-2014-006750. PMID: 25537788.

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MacPherson H, Richmond S, Bland M, Brealey S, Gabe R, Hopton A, Keding A, Lansdown H, Perren S, Sculpher M, Spackman E, Torgerson D, Watt I. Acupuncture and counseling for depression in primary care: a randomized controlled trial. PLoS Med. 2013;10(9):e1001518. doi: 10.1371/journal.pmed. 1001518. Epub 2013 Sep 24. PMID: 24086114.

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New Hampshire Department of Health and Human Services. Provider Notices. Accessed at: https://www.dhhs.nh.gov/ombp/pharmacy/notices.htm

Office of Patient Centered Care and Cultural Transformation (OPCC&CT). Complementary and Integrative Health (CIH) Resource Guide. Version 2. Last Update: 2017 Oct. Accessed at: https://n1s1t23sxna2acyes3x4cz0h-wpengine.netdna-ssl.com/wp-content/uploads/2017/12/CIH- Resource-Guide_Final-Sept-2017-3.pdf

U.S. Department of Veterans Affairs (VA), Department of Defense (DoD). VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain. Version 2.0 – 2017. Accessed at: https://www.healthquality.va.gov/guidelines/Pain/lbp/VADoDLBPCPG092917.pdf

U.S. Department of Veterans Affairs. Department of Defense (DoD). VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness CMI 2014. Accessed at: https://www.healthquality.va.gov/guidelines/mr/cmi/index.asp

U.S. National Library of Medicine. National Institutes of Health. Collection Development Manual. Complementary and Alternative Medicine. 2018 Mar 26. Accessed at: https://www.ncbi.nlm.nih.gov/books/NBK518811/

Wang H, Xie Y, Zhang Q, Xu N, Zhong H, Dong H, Liu L, Jiang T, Wang Q, Xiong L. Transcutaneous electric acupoint stimulation reduces intra-operative remifentanil consumption and alleviates postoperative side-effects in patients undergoing sinusotomy: a prospective, randomized, placebo-controlled trial. Br J Anaesth. 2014 Jun;112(6):1075-82. doi: 10.1093/bja/aeu001. Epub 2014 Feb 26. PMID: 24576720.

Wu MS, Chen KH, Chen IF, Huang SK, Tzeng PC, Yeh ML, Lee FP, Lin JG, Chen C. The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLoS One. 2016 Mar 9; 11(3): e0150367. doi: 10.1371/journal.pone.0150367. PMID: 26959661.

Complementary and Alternative Medicine, Including Acupuncture

Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese medicine for neck pain and low back pain: a systematic review and meta-analysis. PLoS One. 2015 Feb 24;10(2):e0117146. doi: 10.1371/journal.pone.0117146. eCollection 2015. PMID: 25710765.

Policy History Original Effective Original Approval Original Policy Date* and Version Policy Owner Date Approved by Number Regulatory Approval: N/A 11/01/09 Medical Policy Manager MPCTAC and Quality Version 1 as Chair of Medical Policy, Improvement Committee Internal Approval: Criteria, and Technology (QIC) 07/28/09: MPCTAC Assessment Committee 08/26/09: QIC (MPCTAC) *Effective Date for the BMC HealthNet Plan Commercial Product(s): 01/01/12 *Effective Date for the Senior Care Options Product(s): 01/01/16

Policy title was Complementary and Alternative Medicine, Including Acupuncture Treatment until 06/30/19. As of 07/01/19, policy title changed to Complementary and Alternative Medicine, Including Acupuncture.

Policy Revisions History Revision Review Effective Date Summary of Revisions Approved by Date and Version Number 07/01/10 Removed osteopathic manipulation from the list Version 2 07/21/10: MPCTAC of CAM services. Changed the “non-covered” 08/25/10: QIC language to “not medically necessary,” added massage by a massage therapist and updated references. 07/01/11 Updated references and added commercial Version 3 07/22/11: MPCTAC language. 08/24/11: QIC 07/01/12 Updated references, added language to Version 4 07/18/12: MPCTAC Applicable Code section and added applicable 08/22/12: QIC code list. Updated Summary section and Applicable Code section to specify that acupuncture is considered a medically necessary service for Commonwealth Care and MassHealth members when used for substance abuse detoxification, as managed and authorized by Beacon Health Strategies. Included statement that acupuncture is not a covered service for Commercial members and added a reference to the Medically Necessary policy in the Summary

Complementary and Alternative Medicine, Including Acupuncture

Policy Revisions History section. 05/01/13 Review for effective date 09/01/13. Updated 09/01/13 05/15/13: MPCTAC Summary section and applicable code list. Version 5 06/20/13: QIC Referenced Reimbursement Guidelines: Chiropractic Services (Spinal Manipulation), policy number 4.114. Medical Policy Statement section revised without changing criteria. Hippotherapy added to applicable code list, and the reference to the Hippotherapy policy deleted from Medical Policy Statement section (since Hippotherapy policy will be retired effective 09/01/13). Renumbered policy from OCA: 3.193 to OCA: 3.194. 05/01/14 Review for effective date 07/01/14. Updated 07/01/14 05/21/14: MPCTAC Summary section. Added acupuncture services Version 6 06/11/14: QIC in the Description of Item or Service and Clinical Background Information sections. Revised language in Medical Policy Statement section and Limitations section without changing criteria. Updated references. Revised policy title. 01/01/15 Review for effective date 03/01/15. Updated 03/01/15 01/21/15: MPCTAC Medical Policy Statement section to clarify Version 7 02/11/15: QIC guidelines without changing criteria. Updated references. 04/01/15 Review for effective date 06/01/15. Removed 06/01/15 04/15/15: MPCTAC Commonwealth Care, Commonwealth Choice, Version 8 05/13/15: QIC and Employer Choice from the list of applicable products because the products are no longer available. Administrative changes made to the Applicable Coding section, but no changes made to the code list. Updated Summary and References sections. 11/25/15 Review for effective date 01/01/16. Updated 01/01/16 11/18/15: MPCTAC template with list of applicable products and Version 9 11/25/15: MPCTAC notes. Administrative changes made to the (electronic vote) Summary, Medical Policy Statement, and 12/09/15: QIC Limitations section without revising criteria. Revised language in the Applicable Coding section. 04/01/16 Review for effective date 06/01/16. Updated 06/01/16 04/20/16: MPCTAC the Clinical Background Information, References, Version 10 05/23/16: QIC and Reference to Applicable Laws and Regulations sections.

Complementary and Alternative Medicine, Including Acupuncture

Policy Revisions History 04/01/17 Review for effective date 05/08/17. 05/08/17 04/19/17: MPCTAC Administrative changes made to the Medical Version 11 Policy Statement and Applicable Coding sections (without changing the code list or criteria). Updated Definitions, Clinical Background Information, References, and Reference to Applicable Laws and Regulations sections. 02/01/18 Review for effective date 03/01/18. Updated 03/01/18 02/21/18: MPCTAC Description of Item or Service and Other Version 12 Applicable Policies sections. 05/01/18 Review for effective date 06/01/18. 06/01/18 05/16/18: MPCTAC Administrative changes made to the Limitations Version 13 sections. Updated Plan notes in the Applicable Coding section without changing the code list. Removed QHP/ConnectorCare/Employer Choice Direct from the list of applicable products for this policy. Updated Policy Summary, Definitions, References, and Other Applicable Policies sections. 03/01/19 Review for effective date 04/01/19. 04/01/19 03/20/19: MPCTAC Administrative changes made to the Description Version 14 of Item or Service, Limitations, Applicable Coding (with Plan notes added), References, and Other Applicable Policies sections. 04/01/19 Review for effective date 05/01/19. 05/01/19 04/18/19: MPCTAC Administrative changes made to the Policy Version 15 (electronic vote) Summary, Description of Item or Service, Medical Policy Statement, and Limitations sections. Revised the policy title. Removed non- payable code listed as not medical necessary (administrative change) and updated Plan notes in the Applicable Coding section. 12/01/19 Review for effective date 01/01/20. 01/01/20 12/18/19: MPCTAC Administrative changes made to Plan notes in Version 16 the Applicable Coding section, References section, and Reference to Applicable Laws and Regulations section. 04/01/20 Review for effective date 07/01/20. 07/01/20 04/15/20: MPCTAC Administrative changes made to the Policy Version 17 Summary, Clinical Background Information, References, and Reference to Applicable Laws and Regulations sections. Revised the Plan notes in the Applicable Coding section. Add a prior authorization requirement for acupuncture

Complementary and Alternative Medicine, Including Acupuncture

Policy Revisions History for Senior Care Options members in the Medical Policy Statement and Limitations sections. 12/01/20 Review for effective date 01/01/21. 01/01/21 12/16/20: MPCTAC Administrative changes made to the Description Version 18 of Item or Service, Medical Policy Statement, Applicable Coding, and References sections.

Last Review Date 12/01/20

Next Review Date 12/01/21

Authorizing Entity MPCTAC

Other Applicable Policies Medical Policy - Biofeedback in an Outpatient Setting to Treat Incontinence or Constipation, policy number OCA 3.969 Medical Policy - Experimental and Investigational Treatment, policy number OCA 3.12 Medical Policy - Medically Necessary, policy number OCA 3.14 Reimbursement Policy - Acupuncture Services, policy number 4.4 Reimbursement Policy - Community Health Centers and Federally Qualified Health Centers, policy number 4.107 Reimbursement Policy - Chiropractic Services (Spinal Manipulation), policy number 4.114 Reimbursement Policy - General Billing and Coding Guidelines, policy number 4.31 Reimbursement Policy - General Billing and Coding, policy number SCO 4.31 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number 4.108 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number SCO 4.108 Reimbursement Policy - Non-Reimbursed Codes, policy number 4.38 Reimbursement Policy - Physician and Non Physician Practitioner Services, policy number 4.608 Reimbursement Policy - Physician and Non-Physician Practitioner Services, policy number SCO 4.608

Complementary and Alternative Medicine, Including Acupuncture

Reference to Applicable Laws and Regulations 78 FR 48164. Federal Register. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. 2013 Aug 7.

114.3 CMR 17.00. Code of Massachusetts Regulations. Division of Health Care Finance and Policy. Medicine.

130 CMR 410.402. Code of Massachusetts Regulations. Division of Medical Assistance. Definitions. Acupuncture.

130 CMR 410.438. Code of Massachusetts Regulations. Division of Medical Assistance. Acupuncture.

243 CMR 5.00. Code of Massachusetts Regulations. Board of Registration in Medicine. The Practice of Acupuncture.

Commonwealth of Massachusetts. Massachusetts General Laws Mandating that Certain Health Benefits Be Provided By Commercial Insurers, Blue Cross and Blue Shield and Health Maintenance Organizations. Regulatory Citations. 2017 Oct 24.

Commonwealth of Massachusetts. Massachusetts Law about Insurance. A Compilation of Laws, Regulations, and Web Sources on Insurance Law in General. Accessed at: https://www.mass.gov/info- details/massachusetts-law-about-insurance#massachusetts-laws-

Social Security Act § 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.

Disclaimer Information:+ Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs. Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members. The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.

Complementary and Alternative Medicine, Including Acupuncture