Clinical UM Guideline
|Guideline #:||CG-ANC-03||Current Effective Date:||10/08/2013|
|Status:||Reviewed||Last Review Date:||08/08/2013|
Acupuncture is the practice of piercing specific areas of the body along peripheral nerves with needles with the goal of inducing analgesia, relieving pain, alleviating withdrawal symptoms of substance abusers, or treating various non-painful disorders. In acupuncture, the placement of needles into the body is dictated by the location of meridians, thought to mark patterns of energy flow throughout the human body. Acupuncture has four 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.
The use of acupuncture is considered medically necessary for treatment of nausea and vomiting associated with surgery, chemotherapy, or pregnancy provided the individual does not have either of the following:
The use of acupuncture is considered medically necessary for treatment of painful chronic osteoarthritis of the knee or of the hip, if all of the following criteria are met:
Not Medically Necessary:
Acupuncture for any other indication, including but not limited to, the treatment of pain other than specified above, is considered not medically necessary.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|97810||Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient|
|97811||Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)|
|97813||Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient|
|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)|
|99.91||Acupuncture for anesthesia|
|ICD-10 Procedure||ICD-10-PCS draft codes; effective 10/01/2014:|
|8E0H300||Acupuncture using anesthesia|
|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014:|
Acupuncture is one of the oldest, most commonly used medical procedures in the world and recently has become a very popular form of complementary and alternative therapy in the United States. Approximately 1 million people utilize acupuncture annually in the United States for pain relief. Acupuncture theory is based on the premise that energy, called "Qi", travels along prescribed pathways or meridians within the body and is responsible for maintaining good health by providing homeostatic regulation of vital body function. Disturbances in the flow of Qi, either excesses or deficiencies, are thought to result in disease. Acupuncture is a group of procedures or techniques used to stimulate specified points on the body for the purpose of regulating this energy flow. While stimulation of these points, called acupoints, is most often achieved by using very thin metal needles to pierce the skin over these areas, other techniques including pressure, heat, or laser energy can also be used. Although the exact mechanism of action of acupuncture has not been explained in Western medical terms, one theory is that acupuncture modulates pain transmission and the pain response by activation of the endogenous nociceptive system (endorphins, enkephalins, and various neuropeptides) by needle insertion.
In November 1997, a National Institutes of Health Consensus Development Panel (NIHCDP) addressed the use of acupuncture. The 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 Cochrane Library lists many Cochrane Reviews on the use of acupuncture, including for the following conditions: headache, epilepsy, insomnia, restless leg syndrome, asthma, depression, stroke, uterine fibroids, smoking cessation, traumatic brain injury and others (Chen, 2010; Cheong, 2008; Cheuk, 2008, 2011; Cheyk, 2007; Cui, 2008; Law, 2007; Li, 2011; Linde, 2009a, 2009b; Lim, 2011; Manheimer, 2012; Paley, 2011;Smith, 2010, 2011; Verhagen 2007; Walshe, 2012; Wei, 2011; White, 2011; Wong, 2011; Xie, 2008; Zhang, 2010; and Zhu, 2011). The majority of these reviews concluded that there was inadequate scientific data to determine whether acupuncture was superior to placebo.
Recently there have been several additional randomized studies focusing on acupuncture as a treatment of musculoskeletal conditions. With regard to osteoarthritis (OA) of the knee, Berman and colleagues reported on a study of 570 participants. Subjects were randomized to receive a 26-week course of gradually tapering true acupuncture or the same schedule of sham acupuncture. (Berman, 2004) An additional group received educational sessions, consisting of two 6-hour group sessions. The primary outcome measures were Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain and function scores at 8 and 26 weeks. On follow-up, those in the true acupuncture group experienced greater improvement in WOMAC function scores at 8 weeks compared to sham group, and pain score was significantly better at 14 and 26 weeks. However, the major limitation in this study was the large number of dropouts: 25.3% for true acupuncture, 23.0% for sham acupuncture, and 37.9% for the education group. Because there was no significant difference in dropout rates between the true and sham acupuncture groups, the authors concluded after additional testing that attrition probably did not confound the true vs. sham acupuncture differences.
Vas and colleagues (2004) reported on the results of a trial that randomized 97 subjects with OA of the knee to receive either acupuncture or placebo acupuncture with diclofenac. Participants were treated for 12 weeks, when the final assessment was made. A total of 9 individuals dropped out of the study. The primary outcome measures were changes in the WOMAC index and pain scores, using an intent-to-treat analysis. The authors assigned the 1 dropout in the treatment group the worst score for the treatment group as a whole, while the 8 dropouts in the control group were assigned the best scores for the control group. There was a greater reduction in the WOMAC index in the treatment group compared to the control (mean difference between the 2 groups = 23.9%). The study is limited in that there was no attempt to determine the success of the blinding and the short-term follow-up of 12 weeks.
With regard to OA of the hip, Stener-Victorin and colleagues (2004) conducted a study of 45 subjects with hip OA awaiting hip replacement surgery that were randomized to receive either hydrotherapy, electro-acupuncture, or education. While positive results of both electro acupuncture and hydrotherapy were reported compared to no changes in the education group, the small numbers in each group (n=15) require confirmation in larger studies. Nevertheless, this study provides well-designed, if limited, evidence of the safety and efficacy of acupuncture for this indication.
The American College of Rheumatology released their Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee in 2012. Regarding the use of acupuncture, they "conditionally recommend' the use of traditional Chinese acupuncture for patients with OA of the knee. They provide this additional comment with their recommendation:
These modalities are conditionally recommended only when the patient with knee osteoarthritis (OA) has chronic moderate to severe pain and is a candidate for total knee arthroplasty but either is unwilling to undergo the procedure, has comorbid medical conditions, or is taking concomitant medications that lead to a relative or absolute contraindication to surgery or a decision by the surgeon not to recommend the procedure.
In 2013 the American Academy of Orthopaedic Surgeons released their evidence-based Guideline for Treatment of Osteoarthritis of the Knee (AAOS, 2013). In this document they state, "We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of the knee." They rate the strength of this recommendation a "Strong". The rational that accompanies this recommendation says:
There were five high- and five moderate- strength studies that compared acupuncture to comparison groups receiving non-intervention sham, usual care, or education. The five moderate-strength studies were included because they reported outcomes that were different than the high-strength evidence. High-strength studies included: Berman et al., Suarez-Almazor et al., Weiner et al., Williamson et al. and Taechaarpornkul et al. Moderate-strength studies included: Sandgee et al., Vas et al., Witt et al. and Berman et al. The majority of studies were not statistically significant and an even larger proportion of the evidence was not clinically significant. Some outcomes were associated with clinical- but not statistical- significance. The strength of this recommendation was based on lack of efficacy, not on potential harm.
Vas and colleagues investigated the use of acupuncture for the treatment of acute low back pain (2012). In their study 275 subjects to receive conventional treatment alone, or in conjunction with three types of acupuncture; true acupuncture, sham or placebo. Both the evaluators and subjects were blind to treatment group assignment. Follow-up continued through 48 weeks, at which there was an overall loss to follow-up of 23.7%. The primary outcome was a 35% or more reduction in Roland Morris disability Questionnaire scores after more than 2 weeks of treatment. The authors reported that all three acupuncture groups had significantly better results than the conventional treatment group. However, there were no significant differences between the three acupuncture groups. The conclusion was that true acupuncture was not better than sham or placebo.
A large meta-analysis conducted by Vickers and colleagues addressed the use of acupuncture for a variety of chronic pain conditions, including headache, shoulder, musculoskeletal pain, and OA (2012). The analysis included data from 17,922 individuals from 31 RCTs for which the authors could determine sufficient blinding. The report describes a large variation across trials with regard to the type of sham acupuncture used, as well as in other treatments subjects were allowed to have. Additionally, there was also significant variation with regard to what treatments were used in the "usual care" and "no acupuncture" groups. Nonetheless, the authors report that acupuncture was significantly better compared to controls for all analyses. Effect size was larger for analyses comparing acupuncture vs. no acupuncture than vs. sham treatments. An analysis excluding outlier data eliminated any significant findings for comparisons of acupuncture vs. sham. Moreover, several analyses were driven by a few large studies, that when removed from the equation indicated no significant benefits to acupuncture. The authors conclude that acupuncture has a significant benefit, but that aspects of treatment considered crucial to treatment such as correct location and depth of insertion were not vital in outcomes. They continue, concluding that some other aspects of routine clinical practice are responsible for clinically relevant results. This is indicated by the relatively small differences between true acupuncture and sham treatment. The results of this study are very interesting, and call into question the benefits of acupuncture for chronic pain conditions, since there appears to be a significant placebo effect a play in the clinical setting.
Other randomized studies by Vickers and coworkers (2004) and Kvorning et al (2004), focusing on chronic headache and pregnancy-associated back pain, respectively, did not include a sham acupuncture control group, limiting any interpretation of results. A 2005 randomized controlled trial (RCT) on the effects of acupuncture on migraine headache included an active and sham acupuncture group, as well as a control group (Linde, 2005). In this study, the proportion of subjects responding (in terms of reduction in headache days by at least 50%) to either acupuncture or sham acupuncture was 51% and 53% respectively, but only 15% in the no-acupuncture group. There was no difference between real and sham acupuncture in this study; both were superior to control. Another large RCT conducted by Enders and colleagues involved 409 subjects with tension-type headaches randomized to receive verum acupuncture vs. sham treatment (2007). Both investigators and subjects were blind to group assignment. The authors reported that in the intent to treat analysis there was no difference in the rate of response to treatment between groups. However, they did report significant benefits over sham with regards to improvement in headache days (p = 0.004) and International headache Society response criteria (p = 0.024).
A randomized study by White and colleagues of subjects with chronic neck pain reported that acupuncture provided no additional benefit compared to placebo acupuncture (While, 2004). With regard to fibromyalgia, a 2005 randomized trial between acupuncture and sham acupuncture also revealed no significant difference in pain relief between either group (Assefi, 2005).
There is some concern among experts that the use of acupuncture with or without electrical stimulation may interfere with the function of medical devices that are highly sensitive to disruptions in the body's electrical field. Two such devices include pacemakers and automatic implantable cardiac defibrillators (AICDs). These devices monitor very small electrical impulses in the heart. When pre-set thresholds for changes in the heart's electrical function are detected they react by administrating an electrical charge to adjust the pace or rhythm of the heartbeat or, in the case of AICDs, restart a stopped heart. There is some risk that the use of acupuncture may interfere with these devices resulting in misfire of the device, resulting in cardiac complications such as arrhythmia or inadvertent AICD discharge. There is also some concern regarding the use of acupuncture in individuals with bleeding disorders. Acupuncture may pose a bleeding risk in these people, leading to episodes of uncontrolled bleeding. Use of acupuncture in these populations should be used with caution.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Reviewed||8/08/2013||Medical Policy & Technology Assessment Committee (MPTAC) review|
|Reviewed||8/09/2012||MPTAC review. No change to position statement. Updated Rationale and Reference sections. Updated Coding section to remove revenue codes 0374 and 2101.|
|Reviewed||8/18/2011||MPTAC review. No change to position statement. Updated Coding, Rationale and Reference sections.|
|Reviewed||8/19/2010||MPTAC review. No change to position statement.|
|Revised||08/27/2009||MPTAC review. Deleted "bleeding disorders" from medically necessary position statements. Updated Background and Reference sections. Updated Coding section with 10/01/2009 ICD-9 changes.|
|Reviewed||08/28/2008||MPTAC review. No change to position statement|
|Reviewed||08/23/2007||MPTAC review. Clarified position statement regarding the use of acupuncture in the presence of bleeding disorders, AICDs, or pacemakers. Updated Coding and Reference sections.|
|New||09/14/2006||MPTAC review. Transferred content from ANC.00002 Acupuncture to new Clinical Guideline CG-ANC-03 Acupuncture. Not Medically Necessary indications in new guideline previously considered Investigational/Not Medically Necessary. Coding updated; removed CPT 97780, 97781 deleted 12/31/04.|
|Revised||06/08/2006||MPTAC review. Added limits to use of acupuncture for individuals with pacemakers, AICDs, or bleeding disorders; added the use of acupuncture for the treatment of chronic osteoarthritis of the hip and knee as medically necessary; revised Rationale and Reference sections.|
|11/17/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||09/22/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|WellPoint Health Networks, Inc.||No prior document|