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 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.

Medically Necessary:

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:

• Pacemaker; or
• Automatic implantable cardioverter-defibrillator (AICD).

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:

• Radiographic evidence of osteoarthritis; and
• Absence of ALL of the following:
  • Other metabolic, inflammatory, or infectious causes of arthritis; and
  • Pacemaker or AICD; and
  • No plans for total joint replacement; and
• Pain significantly affecting daily activity and function.

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.

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 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 osteoarthritis 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 osteoarthritis of the hip, Stener-Victorin and colleagues (2004) conducted a study of 45 subjects with hip osteoarthritis 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.

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:

1. Assefi N, Sherman KJ, Jacobsen C, et al. A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Ann Intern Med. 2005; 143(1):10-19.
2. Berman BM, Langevin HM, Witt CM, Dubner R. Acupuncture for chronic low back pain. N Engl J Med. 2010; 363(5):454-461.
3. Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2004; 141(12):901-910.
4. Endres HG, Böwing G, Diener HC, et al. Acupuncture for tension-type headache:  a multicentre, sham-controlled, patient- and observer-blinded, randomized trial. J Headache Pain. 2007; 8(5):306-314.
5. Foster NE, Thomas E, Barlas P, et al. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ. 2007; 335(7617):436.
6. Frey UH, Funk M, Löhlein C, Peters J. Effect of P6 acustimulation on post-operative nausea and vomiting in patients undergoing a laparoscopic cholecystectomy. Acta Anaesthesiol Scand. 2009; 53(10):1341-1347.
7. Haake M, Müller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007; 167(17):1892-1898.
8. Jena S, Witt CM, Brinkhaus B, et al. Acupuncture in patients with headache. Cephalalgia 2008; 28(9):969-979.
9. Kvorning N, Holmberg C, Grennert L, et al. Acupuncture relieves pelvic and low-back pain in late pregnancy. Acta Obstet Gynecol Scand. 2004; 83(3):246-250.
10. Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral joint osteoarthritis: a systematic review and meta-analysis. Rheumatology (Oxford). 2006; 45(11):1331-1337.
11. Lao L, Bergman S, Hamilton GR, et al. Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial. Arch Otolaryngol Head Neck Surg. 1999; 125(5):567-572.
12. Linde K, Streng A, Jürgens S, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005; 293(17):2218-2225.
13. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009; 338:a3115.
14. Manber R, Schnyer RN, Lyell D, et al.  Acupuncture for depression during pregnancy: a randomized controlled trial. Obstet Gynecol. 2010; 115(3):511-520.
15. Manheimer E, Linde K, Lao L, et al.  Meta-analysis: acupuncture for osteoarthritis of the knee. Ann Intern Med. 2007; 146(12):868-877.
16. Stener-Victorin E, Kruse-Smidje C, Jung K. Comparison between electro-acupuncture and hydrotherapy, both in combination with patient education and patient education alone, on the symptomatic treatment of osteoarthritis of the hip. Clin J Pain. 2004; 20(3):179-185.
17. Sung YF, Kutner, MH, Cerine FC, Frederickson EL. Comparison of the effects of acupuncture and codeine on postoperative dental pain. Anesth Analg. 1977; 56(4):473-478.
18. Tough EA, White AR, Cummings TM, et al. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomized controlled trials. Eur J Pain. 2009; 13(1):3-10.
19. Vas J, Mendez C, Perea-Milla E, et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ. 2004; 329(7476):1216-1219.
20. Vickers AJ, Rees RW, Zollman C, et al. Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial. BMJ. 2004; 328(7442):744.
21. White P, Lewith G, Prescott P, Conway J. Acupuncture versus placebo for the treatment of chronic mechanical neck pain. Ann Intern Med. 2004; 141(12):911-919.

Government Agency, Medical Society, and Other Authoritative Publications: 

1. Agency for Healthcare Research and Quality. Technology assessment: Acupuncture for fibromyalgia. June 5, 2003. Available at: http://archive.ahrq.gov/clinic/techarch.htm. Accessed on June 6, 2012.
2. Agency for Healthcare Research and Quality. Technology assessment: Acupuncture for Osteoarthritis. June 5, 2003. Available at: http://archive.ahrq.gov/clinic/techarch.htm. Accessed on June 6, 2012.
3. Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment. Number 194. Complementary and Alternative Therapies for Back Pain II. Available at :  http://www.ahrq.gov/downloads/pub/evidence/pdf/backpaincam/backcam2.pdf. Accessed on June 4, 2012.
4. Centers for Medicare and Medicaid Services. National Coverage Determinations. Available at:  http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on June 4, 2012:
   •  Acupuncture. NCD #30.3.
   • Acupuncture for Fibromyalgia. NCD #30.3.1.
   • Acupuncture for Osteoarthritis. NCD #30.3.2.
5. Chen N, Zhou M, He L, et al. Acupuncture for Bell's palsy. Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.: CD002914.
6. Cheong YC, Hung Yu Ng E, Ledger WL. Acupuncture and assisted conception. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006920.
7. Cheuk DKL, Wong V. Acupuncture for epilepsy. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD005062.
8. Cheuk DKL, Yeung J, Chung KF, Wong V. Acupuncture for insomnia. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005472.
9. Cheuk DKL, Wong V, Chen WX. Acupuncture for autism spectrum disorders (ASD). Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD007849.
10. Cui Y, Wang Y, Liu Z. Acupuncture for restless legs syndrome. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006457.
11. Law SK, Li T. Acupuncture for glaucoma. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006030.
12. Lee A, Fan LTY. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003281.
13. Li S, Yu B, Zhou D, He C, Kang L, Wang X, Jiang S, Chen X. Acupuncture for Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD007839.
14. Lim DCE, Chen W, Cheng LNC, Xue CC, Wong FWS, O'Sullivan AJ, Liu JP. Acupuncture for polycystic ovarian syndrome. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD007689.
15. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews 2009a, Issue 1. Art. No.: CD001218.
16. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache. Cochrane Database of Systematic Reviews 2009b, Issue 1. Art. No.: CD007587.
17. Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001977.
18. Manheimer E, Cheng K, Wieland LS, Min LS, Shen X, Berman BM, Lao L. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD005111.
19. Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in adults. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD007753.
20. Rathbone J, Xia J. Acupuncture for schizophrenia. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD005475.
21. Richmond J, Hunter D, Irrgang J, et al; American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg. 2009; 17(9):591-600.
22. Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD009232.
23. Smith CA, Hay PPJ, MacPherson H. Acupuncture for depression. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD004046.
24. Smith CA, Zhu X, He L, Song J. Acupuncture for primary dysmenorrhoea. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD007854.
25. Trinh K, Graham N, Gross A, et al; Cervical Overview Group. Acupuncture for neck disorders. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004870.
26. Verhagen AP, Scholten-Peeters GGGM, van Wijngaarden S, et al. Conservative treatments for whiplash. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD003338.
27. Walshe M, Smith M, Pennington L. Interventions for drooling in children with cerebral palsy. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD008624.
28. Wei ML, Liu JP, Li N, Liu M. Acupuncture for slowing the progression of myopia in children and adolescents. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD007842.
29. White AR, Rampes H, Liu JP, et al. Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD000009.
30. Wong V, Cheuk DKL, Lee S, Chu V. Acupuncture for acute management and rehabilitation of traumatic brain injury. Cochrane Database of Systematic Reviews 2011, Issue 5. Art. No.: CD007700.
31. Xie Y, Wang L, He J, Wu T. Acupuncture for dysphagia in acute stroke. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006076.
32. Zhang Y, Peng W, Clarke J, Liu Z. Acupuncture for uterine fibroids. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007221.
33. Zhu X, Hamilton KD, McNicol ED. Acupuncture for pain in endometriosis. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD007864.

Acupuncture
Alternative Medicine
Electroacupuncture
Nausea
Osteoarthritis
Vomiting