ARCHIVED

Medical Policy

Policy Num:      10.002.010
Policy Name:     Acupuncture
Policy ID:          [10.002.010][Ar L M+ P ][7.01.01]

Last Review:       April 20, 2022
Next Review:      N/A
Issue:                   April, 2022

Related Policies: None

Archived

Acupuncture

Summary

Acupuncture is the practice of piercing the skin with needles at specific body sites to induce anesthesia, to relieve pain to alleviate withdrawal symptoms of substance abusers, or to treat various non-painful disorders. The placement of needles into the skin is dictated by the location of meridians. These meridians are thought to mark patterns of energy flow throughout the human body. Acupuncture has 4 components—the acupuncture needle(s), the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle. Acupuncture may be performed with or without electrical stimulation. Acupuncture is a traditional form of Chinese medical treatment that has been practiced for over 3,000 years. The U.S. Food and Drug Administration (FDA) has cleared acupuncture needles for marketing. The needles used in acupuncture, when intended for general use in “the performance of acupuncture,” have been classified by the FDA as Class II devices (The Gray Sheet, April 8, 1996).

Objective

The objective of this local policy is to establish medical necessity of acupuncture.

Policy Statements

Acupuncture may be considered medically necessary for treatment of the following conditions:

1. Chronic neck pain

2. Chronic headache

3. Low back pain

4. Pain from osteoarthritis of the knee or hip (adjunctive therapy)

5.  Post-operative dental pain

6. Temporomandibular disorders (TMD).

7.  Post-operative and chemotherapy-induced nausea and vomiting

8.  Nausea of pregnancy

Acupuncture for any other indication, including but not limited to acupuncture for the treatment of pain, is considered investigational.

Policy Guidelines

See codes section.

Benefit Application

Acupuncture is considered within the scope of practice of a licensed physician. However, some physicians may seek additional training in acupuncture. Non-physicians who have completed appropriate training may also be licensed to perform acupuncture. State regulations may affect the range of providers offering acupuncture.

Background

Acupuncture is system of integrative medicine that involves pricking the skin or tissues with needles, used to alleviate pain and to treat various physical, mental, and emotional conditions. Originating in ancient China, acupuncture is now widely practiced in the West.

 Acupuncture is a complementary medical practice that entails stimulating certain points on the body, most often with a needle penetrating the skin, to alleviate pain or to help treat various health conditions. Developed millennia ago in China, numerous recent studies conducted by scientists in Europe and the United States have found that acupuncture is at least moderately effective in treating pain and nausea. 

For example, one of the largest studies to date on acupuncture and chronic pain — a meta-analysis of 29 well-conducted studies involving nearly 18,000 patients and published in October 2012 in the Archives of Internal Medicine — found that acupuncture is effective for treating chronic pain and therefore is a reasonable referral option. The doctors wrote that "[s]ignificant differences between true and sham acupuncture indicate that acupuncture is more than a placebo" but added that "these differences are relatively modest." 

Acupuncture points are believed to stimulate the central nervous system. This, in turn, releases chemicals into the muscles, spinal cord, and brain. These biochemical changes may stimulate the body's natural healing abilities and promote physical and emotional well-being. 

More than four hundred acupuncture points have been described, with the majority located on one of the main meridians, pathways which run throughout the body and according to Traditional Chinese Medicine (TCM) transport life energy (qi, 氣). TCM recognizes twenty meridians, cutaneous and subcutaneous in nature, which have branching sub-meridians believed to affect surrounding tissues. Twelve of these major meridians, commonly referred to as "the primary meridians", are bilateral and are associated with internal organs. The remaining eight meridians are designated as "extraordinary", and are also bilateral except for three, one that encircles the body near the waist, and two that run along the midline of the body. Only those two extraordinary meridians that run along the midline contain their own points, the remaining six comprise points from the aforementioned twelve primary meridians. There are also points that are not located on the fourteen major meridians but do lie in the complete nexus referred to as jing luo (經絡). Such outliers are often referred to as "extra points"

The most common side effects of acupuncture include bleeding, soreness, or bruising at the site of needle insertion. Other risks of acupuncture include dizziness, fainting, local internal bleeding, convulsions, hepatitis B, dermatitis, nerve damage, increased pain, and very rarely injury to an internal organ.

Regulatory Status

Acupuncture is considered within the scope of practice of a licensed physician

Rationale

Population Reference No. 1 Policy Statement

Chronic Neck Pain

In a review on the safety and effectivenes of various interventions for the treatment of neck pain, Binder (2008) stated that compared with sham treatment, inactive treatment, or waiting list control, acupuncture may be more effective than some types of sham treatment (not further defined) or inactive treatment (not further defined) at improving pain relief at the end of treatment or in the short-term (less than 3 months), but not in the intermediate-term (not defined) or in the long-term (not defined) in people with chronic mechanical disorders.  The author also noted that acupuncture may be more effective than sham TENS at improving pain at 1 week after treatment, and at 6 months, in people with chronic neck pain.  Needle acupuncture may be more effective than no acupuncture at improving a composite outcome of neck pain and disability (not further defined) at 3 months in people with chronic neck pain (very low-quality evidence).  Furthermore, compared with sham treatment, inactive treatment, or waiting list control, needle acupuncture may be more effective than no acupuncture at improving quality of life (measured by SF-36) at 3 months in people with chronic neck pain (very low-quality evidence). The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 2 Policy Statement

Chronic Headache

There is evidence to support the use of acupuncture in migraine.  In a large randomized controlled study (n = 401), Vickers et al (2004) examined the effects of a policy of "use acupuncture" on headache (predominantly migraine), health status, days off sick, and use of resources in patients with chronic headache compared with a policy of "avoid acupuncture".  Patients were randomly allocated to receive up to 12 acupuncture treatments over 3 months or to a control intervention offering usual care.  Headache score, SF-36 health status, and use of medication were assessed at baseline, 3, and 12 months.  Use of resources was assessed every 3 months.  Headache score at 12 months, the primary end point, was lower in the acupuncture group (16.2, SD 13.7, n = 161, 34 % reduction from baseline) than in controls (22.3, SD 17.0, n = 140, 16 % reduction from baseline).  The adjusted difference between means is 4.6 (95 % confidence interval [CI]: 2.2 to 7.0; p = 0.0002).  This result is robust to sensitivity analysis incorporating imputation for missing data.  Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year (8 to 38).  SF-36 data favored acupuncture, although differences reached significance only for physical role functioning, energy, and change in health.  Compared with controls, patients randomized to acupuncture used 15 % less medication (p = 0.02), made 25 % fewer visits to general practitioners (p = 0.10), and took 15 % fewer days off sick (p = 0.2).  The authors concluded that acupuncture leads to persisting, clinically relevant benefits for primary care patients with chronic headache, particularly migraine. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 3 Policy Statement

Chronic Low Back Pain

There is evidence to support the use of acupuncture in treating chronic low back pain (LBP).  In a prospective cohort study, Kukuk et al (2005) ascertained the long-term effects 3 and 6 months after the end of a course of acupuncture treatment for chronic LBP or chronic pain caused by gonarthrosis.  A total of 1,096 eligible patients with chronic LBP or gonarthrosis pain were identified (68.1 % female) and invited by letter to participate in the study.  Ultimately 249 patients remained, with no loss of representativeness.  Two telephone interviews were conducted 3 and 6 months after the last acupuncture session using standardized questionnaires, available as electronic case report forms.  The primary target criteria were self-assessment of pain tolerability before the start of acupuncture and after the end of treatment, and pain intensity (GCPS) over time.  Secondary target criteria were changes to functional impairment (HFAQ for chronic LBP, WOMAC for gonarthrosis), quality of life (SF12), depression (CES-D) and patient global assessment of treatment effectiveness (PGA).  For the indication chronic LBP, pain-related fear avoidance beliefs (FABQ) were also queried.  These investigators found that pain tolerability was significantly improved after acupuncture and remained so up to 6 months after treatment.  The mean scores of almost all questionnaires did not change significantly between 3 and 6 months.  They concluded that acupuncture had a long-term effect on important aspects of cognitive and emotional pain coping. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 4 Policy Statement

Pain from Osteoarthritis of the Knee or Hip

There is some evidence to support the use of acupuncture for treatment of hip and knee osteoarthritis.  An earlier AHRQ technology assessment (2003) on Acupuncture for Osteoarthritis concluded that "The currently available evidence is insufficient to determine whether acupuncture has a specific beneficial effect in osteoarthritis."  However, a Cochrane review of acupuncture for peripheral joint osteoarthritis (Manheimer et al, 2010) concluded that sham-controlled trials show statistically significant benefits; the authors stated, however, that these benefits are small, do not meet the authors' pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding.  The authors found that waiting list-controlled trials of acupuncture for peripheral joint osteoarthritis suggest statistically significant and clinically relevant benefits, much of which may be due to expectation or placebo effects. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 5 Policy Statement

Post-operative Dental Pain

There is some evidence to support the use of acupuncture for treatment of port-operative dental pain. Acupuncture appears to be useful for treatment and prevention of postoperative pain after dental surgery such as tooth extraction. It may work better at preventing pain rather than treating moderate-to-severe pain. When used intraoperatively, acupuncture does not appear to change pain intensity postoperatively, but it may allow for less intraoperative medication. The length of time needed to treat, the frequency of treatments, and whether acupuncture is synergistic with conventional medicine all currently are unknown. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 6 Policy Statement

Temporomandibular disorders (TMD)

There is some evidence to support the use of acupuncture for treatment of TMD. In A PRISMA-compliant meta-analysis Jun-Yi Wu et al (2017) indicate that conventional acupuncture therapy is effective in reducing the degree of pain in patients with TMD, especially those with myofascial pain symptoms. This study compared the clinical effectiveness of acupuncture therapy in TMD patients through the meta-analysis of published results. Results indicate that acupuncture therapy penetrating the skin has greater effectiveness and reduces the pain degree to a greater extent, especially myofascial pain symptoms, compared with both sham nonpenetrating acupuncture and sham laser therapy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 7 Policy Statement

Post-operative and chemotherapy-induced nausea and vomiting

There is good clinical evidence from more than 40 randomised controlled trials that acupuncture has some effect in preventing or attenuating nausea and vomiting. A growing number of experimental studies suggest mechanisms of action. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 1 Policy Statement

Nausea of pregnancy

There is good clinical evidence from more than 40 randomised controlled trials that acupuncture has some effect in preventing or attenuating nausea and vomiting. A growing number of experimental studies suggest mechanisms of action. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Supplemental Information

Practice Guidelines and Position Statements

National Institutes of Health Consensus Development Panel A 1997 Consensus Statement concluded that evidence clearly shows that needle acupuncture is efficacious in treating nausea secondary to surgery or chemotherapy in adults, and probably effective for nausea of pregnancy as well. The document also states that there is evidence of efficacy for postoperative dental pain. The Panel made a more equivocal statement that acupuncture "may be useful" in the following conditions: addiction, stroke rehabilitation, headache, menstrual cramps, lateral elbow pain, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma.

Guidelines from the American College of Physicians (Qaseem, et al., 2017) recommend the use of acupuncture in the management of acute and subacute low back pain. The guidelines state that, "[g]iven that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation). The guidelines also recommend acupuncture for chronic low back pain. "For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).

Medicare National Coverage

 The Centers for Medicare & Medicaid Services (CMS) as defined in NCD 30.3.3 will cover acupuncture for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:

• For the purpose of this decision, chronic low back pain (cLBP) is defined as:
  • Lasting 12 weeks or longer;
  • nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
  • not associated with surgery; and
  • not associated with pregnancy.
• An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.
• Treatment must be discontinued if the patient is not improving or is regressing.

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289. CMS NCD

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