Dry Needling Policy Number: PG0465 ADVANTAGE | ELITE | HMO Last Review: 07/26/2021 INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder terms, conditions, exclusions and limitations contract. It does not constitute a contract or guarantee regarding coverage or reimbursement/payment. Self-Insured group specific policy will supersede this general policy when group supplementary plan document or individual plan decision directs otherwise. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This medical policy is solely for guiding medical necessity and explaining correct procedure reporting used to assist in making coverage decisions and administering benefits. SCOPE X Professional X Facility DESCRIPTION Dry needling refers to a procedure in which a thin filiform needle is inserted into the skin and muscle at a site of myofascial pain. The physiological basis for dry needling depends on the targeted tissue and treatment objectives. The intent is to stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Deep dry needling is believed to inactivate trigger points by eliciting contraction and subsequent relaxation of the taut band via a spinal cord reflex. Superficial dry needling is thought to activate mechanoreceptors and have an indirect effect on pain by inhibiting C-fiber pain impulses. Dry needling is not to be confused with traditional Chinese acupuncture, even though it does make use of acupuncture-type needles. Acupuncture follows the principles of energy flow as a guide to where the needles will be inserted; in dry needling, Needles are inserted directly into a myofascial trigger point, in an attempt to inactivate it, thereby decreasing the associated pain. Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated. Dry needling, even though it targets a trigger point, also differs from a trigger point injection, as there is no injection of medication or fluid. There is preliminary evidence that dry needling of trigger points is effective for short-term pain relief, and to improve quality of life and range of motion when compared to a placebo. However, further studies of high quality and with a standardized needling procedure are needed to support any health outcomes or benefits associated with this procedure. POLICY HMO, PPO, Individual Marketplace Dry needling is considered investigational for all applications. Dry needle trigger point injections (CPT 20560, 20561) for Commercial and Medicaid members are not considered medically necessary due to insufficient evidence of therapeutic value. Advantage Effective 7/1/2021 procedures 20560 and 20561 are covered, per The Ohio Department of Medicaid, for medically indicated services. PG0465 – 07/26/2021 Elite/ProMedica Medicare Plan Effective 6/1/2021 Paramount will cover acupuncture dry needling for Elite/ProMedica Medicare Plan Members with chronic lower back pain within specific guidelines in accordance with Medical Policy PG0382 Acupuncture. All other indications for dry needling is noncovered due to insufficient evidence of therapeutic value, including but not all-inclusive; dry needle trigger point injections. COVERAGE CRITERIA HMO, PPO, Individual Marketplace Paramount considers dry needling for trigger points (i.e., needle insertion without injection) experimental/investigational, as it is not identified as widely used and generally accepted. Although there are ongoing studies, there is little scientifically based data that their use results in improved patient outcomes in the medical literature. Advantage While there is insufficient evidence in the published medical literature to demonstrate the safety, efficacy and long- term outcomes of dry needling injections, The Ohio Department of Medicaid requires coverage for medically indicated services. Elite/ProMedica Medicare Plan Effective 6/1/2021 Dry Needling is covered for Elite/ProMedica Medicare Plan Members per coverage criteria documented in Medical Policy PG0382 Acupuncture: Refer to Medical Policy PG0382 Acupuncture. Diagnosis M54.5 Low Back Pain HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage Dry Needling is additionally addressed in Medical Policies: PG0354 Intervention Pain Management Injection PG0432 Temporomandibular Joint Disorders PG0150 Chiropractic Services & Spinal Manipulation Alternative nonpharmacological treatment modalities for trigger point pain include manual techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, and spray cooling with manual stretch. CODING/BILLING INFORMATION The inclusion or exclusion of a code in this section does not necessarily indicate coverage. Codes referenced in this clinical policy are for informational purposes only. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. CPT CODES 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) 20561 Needle insertion(s) without injection(s); 3 or more muscle(s) 20999 Unlisted procedure, musculoskeletal system, general. (when utilized for dry needling) Because dry needling is not acupuncture, CPT codes 97810-97814 are not appropriate. Paramount reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to https://www.paramounthealthcare.com/services/providers/medical-policies/ . REVISION HISTORY EXPLANATION ORIGINAL DATE: 02/01/2020 PG0465 – 07/26/2021 Date Explanation & Changes 12/08/2020 Medical Policy placed on the new Paramount Medical Policy Format Updated Medical Policy to allow coverage for Dry Needling for Elite/ProMedica Medicare Plan Members with chronic lower back pain within specific guidelines in accordance with Medical Policy PG0382 Acupuncture. Per CMS: “...all types of acupuncture including dry 04/26/2021 needling for any condition other than chronic low back pain are non-covered by Medicare. Medicare will cover acupuncture for Medicare patients with chronic lower back pain within specific guidelines in accordance with NCD 30.3.3”. Effective 07/01/2021 procedures 20560 and 20561 are covered per the ODM Appendix DD fee 07/26/2021 schedule and the EAPG fee schedule, no prior authorization required. REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets U.S. Preventive Services Task Force, http://www.uspreventiveservicestaskforce.org/ Industry Standard Review Hayes, Inc. Industry Standard Review PG0465 – 07/26/2021 .