7/11/2017 Acupuncture Services for Commercial Plans

Oxford Health Plans > Brokers' Resources > Medical & Administrative Policies > Acupuncture Services for Commercial Plans

Title of Medical Policy

Acupuncture Services for Commercial Plans

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies
do not apply to Oxford Medicare Advantage Members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless
otherwise required by Oxford's administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine
whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the
Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

Coverage Statement

Policy is applicable to:

Commercial plans

For Oxford Medicare Advantage® plans, refer to Standard and Expedited Complaints and Grievances for Medicare Advantage

Note:
All Members have specific benefit limitations/benefit maximums determined by group and individual plans. Please refer to the
Member's health benefits plan for specific limitations/ maximums.

Conditions of Coverage

Benefit Type Alternative Medicine1

Referral Required No
(Does not apply to non-
gatekeeper products)
Authorization No
(Precertification always
required for inpatient
admission)
Precertification with No
MD Review
Site(s) of Service Office
(If not listed, MD Review
required)
Special 1NJ Small Group and Individual plans only: Acupuncture in lieu
Considerations of anesthesia is from the General benefit package

Description of Service, Assessment, and Background Information

Acupuncture is the gentle insertion of hair-fine needles into specific points in the body to help stimulate the flow of one's Qi (pronounces chee)
or natural healing energies. Acupuncturists work to relieve obstructions in energy channels that interrupt the flow of energy in the body. Applying
needles to the acupuncture points releases chemicals in the nervous system that help to moderate pain and to stimulate the body's natural
healing abilities. While considered a non-traditional treatment in Western medicine, acupuncture has been practiced in China for thousands of
years.

Acupuncture has been endorsed by the National Institutes of Health (NIH) as an appropriate treatment for pain and nausea. It also
may be useful as an adjunct treatment, an acceptable alternative or be included in a comprehensive management program for
addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back
pain, carpal tunnel syndrome, and asthma.

Policy and Rationale

Oxford Health Plans covers acupuncture services for those Commercial groups that have purchased the Alternative Medicine Rider. Coverage
will be provided on an in network basis only when rendered by an eligible provider.

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Acupuncture Services may also be obtained through the Complementary and Alternative Medicine (CAM) Contracted Rate Program.

Treatment/Applications Guidelines
The following are considered eligible providers:

Participating Licensed Acupuncturist (LAC)

Participating Licensed Naturopaths. Refer to Naturopathic Services for Connecticut Commercial Lines of Business
Participating Physicians (MD or DO) who have been credentialed as physician Acupuncturists

Acupuncture is not reimbursed for:

Continued repetitive treatment without an achievable and clearly defined goal. (This is considered maintenance care.)
Any treatment rendered outside the practitioner's state licensed scope of practice
Weight loss
Smoking cessation

Acupuncture is not recommended for:

Anesthesia

Exception: for New Jersey Small groups and Individual Commercial Plans

In place of anesthesia for routine vaginal deliveries

Exception: for New Jersey Small Groups and Individual Commercial Plans

Applicable CPT Codes

Applicable
CPT Description
Codes
Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of
97810
personal one on one contact with the patient.
Acupuncture, one or more needles; without electrical stimulation, each additional 15
97811 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)
(List separately in addition to code for primary procedure)
Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes of
97813
personal one-on-one contact with the patient
Acupuncture, one or more needles; with electrical stimulation, each additional 15
97814 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)
(List separately in addition to code for primary procedure)
New patient, office or other outpatient visit for the evaluation and management of a
new patient, which requires these three components; a problem focused history; a
problem focused examination; and straightforward medical decision making.
99201 Counseling and/ or coordination of care with other providers or agencies are provided
consistent with the nature of the problem)(s) and the patient's and / or family's needs.
Usually, the presenting problems are self limited or minor; Physicians typically spend
10 minutes face to face with the patient and/or family.
New patient, office or other outpatient visit for the evaluation and management of a
new patient, which requires these three components; an expanded problem focused
history; an expanded problem focused examination; and straightforward medical
99202 decision making. Counseling and/ or coordination of care with other providers or
agencies are provided consistent with the nature of the problem)(s) and the patient's
and / or family's needs. Usually, the presenting problems are self limited or minor;
Physicians typically spend 20 minutes face to face with the patient and/or family.
New patient, office or other outpatient visit for the evaluation and management of a
new patient, which requires these three components; a detailed history; a detailed
examination; and medical decision making of low complexity. Counseling and/ or
99203 coordination of care with other providers or agencies are provided consistent with the
nature of the problem)(s) and the patient's and / or family's needs. Usually, the
presenting problems are self limited or minor; Physicians typically spend 30 minutes
face to face with the patient and/or family.
Office or other outpatient visit for the evaluation and management of an established
patient, which requires these three components; an expanded problem focused
history; an expanded problem focused examination; and straightforward medical
99211 decision making. Counseling and/ or coordination of care with other providers or
agencies are provided consistent with the nature of the problem)(s) and the patient's
and / or family's needs. Usually, the presenting problems are self limited or minor;
Physicians typically spend 20 minutes face to face with the patient and/or family.

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99212 Office or other outpatient visit for the evaluation and management of an established
patient, which requires these three components; an expanded problem focused
history; an expanded problem focused examination; and straightforward medical
decision making. Counseling and/ or coordination of care with other providers or
agencies are provided consistent with the nature of the problem)(s) and the patient's
and / or family's needs. Usually, the presenting problems are self limited or minor;
Physicians typically spend 20 minutes face to face with the patient and/or family.
Office or other outpatient visit for the evaluation and management of an established
patient, which requires these three components; a detailed history; a detailed
examination; and medical decision making of low complexity. Counseling and/ or
99213 coordination of care with other providers or agencies are provided consistent with the
nature of the problem)(s) and the patient's and / or family's needs. Usually, the
presenting problems are self limited or minor; Physicians typically spend 30 minutes
face to face with the patient and/or family.

References
1. American Medical Association. Current Procedural Terminology: CPT 2006, Professional Edition. AMA press, 2005

2. ECRI Hotline Response™ Response: Acupuncture for Chronic Pain Management. 11/12/2004. Retrieved 12/20/2004.

3. ECRI Health Technology Forecast™: Arthritis Pain. 12/17/2004. Retrieved 12/20/2004.

4. ECRI Hotline Response™: Acupuncture for Chronic Headache and Migraine. 11/09/2004. Retrieved 12/20/2004.

5. ECRI Hotline Response™: Dry Needling for Pain Management. 11/30/2004. Retrieved 12/20/2004.

6. ECRI Hotline Response™: Acupuncture for the Treatment of Nausea Associated with Post-Operative Surgery, Chemotherapy or
Pregnancy. 11/05/2003. Retrieved 12/20/2004.

7. New Jersey Small and Individual Certificates

8. White AR. A review of controlled trials of acupuncture for women's reproductive health care. Journal of Family Planning & Reproductive
Health Care. 29(4):233-6, 2003 Oct.

9. Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AMK, Hochberg MC. Effectiveness of Acupuncture as Adjunctive Therapy in
Osteoarthritis of the Knee: A Randomized, Controlled Trial. Annals of Internal Medicine. 2004; 141(12):901-910.

10. 10. Kaptchuk TJ. Acupuncture: Theory, efficacy, and practice. ANNALS OF INTERNAL MEDICINE 136 (5): 374-383 MAR 5 2002

11. Vas J, Mendez C, Perea-Milla E, Vega E, Panadero MD, Leon JM, Borge MA, Gaspar O, Sanchez-Rodriguez F, Aguilar I, Jurado R.
Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomized controlled trial.
BRITISH MEDICAL JOURNAL 329 (7476): 1216-1219 NOV 20 2004

12. Ezzo J, Hadhazy V, Birch S, Lao LX, Kaplan G, Hochberg M, Berman B. Acupuncture for osteoarthritis of the knee - A systematic review.
ARTHRITIS AND RHEUMATISM 44 (4): 819-825 APR 2001

13. Kaptchuk TJ. Acupuncture: Theory, efficacy, and practice. ANNALS OF INTERNAL MEDICINE 136 (5): 374-383 MAR 5 2002

14. Oxford Certificate of Coverage and Member Handbook

15. Alternative Medicine Rider filings

16. NIH Consensus Statement 1997 Nov 3-5; 15(5): 1-34. http://odp.od.nih.gov/consensus/cons/107/107_intro.htm

Alternative 004.5 T0
Effective Date: January 1, 2006

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