CLINICAL GUIDELINES Acupuncture Services Version 1.0.2019 Clinical guidelines for medical necessity review of chiropractic services. © 2019 eviCore healthcare. All rights reserved. Asuris Musculoskeletal Benefit Management Program: Acupuncture Services V1.0.2019 Please note the following: CPT Copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. © 2019 eviCore healthcare. All rights reserved. Page 2 of 554 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com Asuris Musculoskeletal Benefit Management Program: Acupuncture Services V1.0.2019 Dear Provider, This document provides detailed descriptions of eviCore’s basic criteria for musculoskeletal management services. They have been carefully researched and are continually updated in order to be consistent with the most current evidence-based guidelines and recommendations for the provision of musculoskeletal management services from national and international medical societies and evidence-based medicine research centers. In addition, the criteria are supplemented by information published in peer reviewed literature. Our health plan clients review the development and application of these criteria. Every eviCore health plan client develops a unique list of CPT codes or diagnoses that are part of their musculoskeletal management program. Health Plan medical policy supersedes the eviCore criteria when there is conflict with the eviCore criteria and the health plan medical policy. If you are unsure of whether or not a specific health plan has made modifications to these basic criteria in their medical policy for musculoskeletal management services, please contact the plan or access the plan’s website for additional information. eviCore healthcare works hard to make your clinical review experience a pleasant one. For that reason, we have peer reviewers available to assist you should you have specific questions about a procedure. For your convenience, eviCore’s Customer Service support is available from 7 a.m. to 7 p.m. Our toll free number is (800) 918-8924. Gregg P. Allen, M.D. FAAFP EVP and Chief Medical Officer © 2019 eviCore healthcare. All rights reserved. Page 3 of 554 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com Asuris Musculoskeletal Benefit Management Program: Acupuncture Services V1.0.2019 Table of Contents ACU-1.0: Covered Services and Exclusions ............................................................... 7 ACU-1.1: Acupuncture Covered Services .................................................................... 8 ACU-1.2: Medically Necessary Acupuncture Services ................................................ 8 ACU-1.3: Care Classifications ..................................................................................... 8 ACU-1.4: Acupuncture Coverage Exclusions .............................................................. 9 ACU-1.5: Specific Acupuncture Services that are Limited or Excluded ..................... 10 ACU-2.0: Headaches ................................................................................................... 13 ACU-2.1: Cervicocranial Syndrome ........................................................................... 14 ACU-2.2: Headache, Cephalgia ................................................................................ 14 ACU-2.3: Migraine With Aura .................................................................................... 24 ACU-2.4: Migraine Without Aura ............................................................................... 36 ACU-2.5: Unspecified Migraine Headache ................................................................ 47 ACU-3.0: Cervical Conditions (Disc Radicular) ........................................................ 58 ACU-3.1: Brachial Neuritis ......................................................................................... 59 ACU-3.2: Cervical, Degeneration of Intervertebral Disc ............................................. 69 ACU-3.3: Cervical, Post-Surgical Syndrome ............................................................. 79 ACU-3.4: Cervical Stenosis ....................................................................................... 91 ACU-3.5: Cervicobrachial Syndrome ....................................................................... 100 ACU-4.0: Cervical Conditions (Non-Specific) ......................................................... 110 ACU-4.1: Cervicalgia ............................................................................................... 111 ACU-4.2: Cervical Spondylosis ................................................................................ 119 ACU-4.3: Cervical Sprain/Strain .............................................................................. 128 ACU-5.0: Thoracic Conditions ................................................................................. 138 ACU-5.1: Thoracic Intervertebral Disc Syndrome without Myelopathy .................... 139 ACU-5.2: Thoracic Outlet Syndrome ....................................................................... 149 ACU-6.0: Lumbosacral Conditions (Disc Radicular) .............................................. 158 ACU-6.1: Lumbar Degenerative Disc Disease ......................................................... 159 ACU-6.2: Lumbar, Post-Surgical Syndrome ............................................................ 169 ACU-6.3: Lumbar Radiculopathy and Sciatica ......................................................... 181 ACU-7.0: Lumbosacral Conditions (Non-Specific) ................................................. 191 ACU-7.1: Lumbago, Backache NOS ........................................................................ 192 ACU-7.2: Lumbar Spondylosis ................................................................................ 201 ACU-7.3: Lumbar Sprain/Strain ............................................................................... 211 ACU-7.4: Lumbosacral Sprain/Strain ....................................................................... 221 ACU-7.5: Sacroiliac Sprain/Strain ............................................................................ 230 © 2019 eviCore healthcare. All rights reserved. Page 4 of 554 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com Asuris Musculoskeletal Benefit Management Program: Acupuncture Services V1.0.2019 ACU-8.0: Upper Extremity Conditions ..................................................................... 239 ACU-8.1: Bursitis of the Shoulder and Rotator Cuff Syndrome ............................... 240 ACU-8.2: Carpal Tunnel Syndrome (Now Excluded) ............................................... 247 ACU-8.3: Forearm, Joint Pain and Osteoarthrosis................................................... 252 ACU-8.4: Hand, Joint Pain and Osteoarthrosis ....................................................... 259 ACU-8.5: Lateral Epicondylitis ................................................................................. 266 ACU-8.6: Medial Epicondylitis ................................................................................. 273 ACU-8.7: Radial Nerve Entrapment ......................................................................... 280 ACU-8.8: Shoulder, Adhesive Capsulitis ................................................................. 288 ACU-8.9: Shoulder, Joint Pain and Osteoarthrosis .................................................. 295 ACU-8.10: Upper Extremity Post-Surgical ............................................................... 302 ACU-8.11: Wrist Sprain/Strain ................................................................................. 312 ACU-9.0: Lower Extremity Conditions ..................................................................... 319 ACU-9.1: Ankle and Foot, Joint Pain and Osteoarthrosis ........................................ 320 ACU-9.2: Ankle Sprain (Now Excluded) .................................................................. 328 ACU-9.3: Chrondromalacia Patella .......................................................................... 333 ACU-9.4: Hip, Joint Pain and Osteoarthrosis ........................................................... 340 ACU-9.5: Knee, Joint Pain and Osteoarthrosis ........................................................ 349 ACU-9.6: Knee, Tear, Medial Meniscus ................................................................... 357 ACU-9.7: Lower Extremity Post-Surgical ................................................................. 365 ACU-9.8: Piriformis Syndrome ................................................................................. 376 ACU-9.9: Plantar Fasciitis ........................................................................................ 383 ACU-9.10: Thigh Sprain Strain; Unspecified Site of Hip and Thigh ......................... 390 ACU-10.0: Unlisted Musculoskeletal Disorders ...................................................... 400 ACU-11.0: Neuromusculoskeletal Conditions (Unspecified Region) .................... 412 ACU-11.1: Adjunct Care for Post-Stroke Rehabilitation ........................................... 413 ACU-11.2: Fibromyalgia (Now Excluded) ................................................................ 425 ACU-11.3: Jaw Pain, Unspecified ............................................................................ 431 ACU-11.4: Myalgia ..................................................................................................