This policy version was replaced October 31, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Acupuncture involves the stimulation of anatomical points on the body using a variety of techniques. Acupuncture methods have been used to relieve pain, induce anesthesia, alleviate the symptoms of substance withdrawal, and to treat various disorders. The term "maintenance therapy" in context of this policy refers to therapy conducted after initial therapeutic goals of acupuncture have been achieved via objective measurement of symptom improvement or when no additional functional decline due to pain has occurred.

The acupuncture technique that has been most often studied involves penetrating the skin at specific points throughout the body with thin, solid, metallic needles that are manipulated by hand or by electrical stimulation, known as electroacupuncture. In needle acupuncture, 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.

Electrical stimulation of auricular acupuncture points is based on the theory that all acupuncture points are located on the external part of the ear and that each treated point triggers electrical impulses from the ear to the brain and then to the specific body part being treated. This technique differs from placement of manual acupuncture or electroacupuncture techniques which are based on the location of specific meridians as noted above.

Auricular electrical stimulation devices provide pulsed, low-intensity current to auricular acupuncture sites over several days. Auricular electrical stimulation devices have been cleared for marketing through the U.S. Food and Drug Administration (FDA) through the 510(k) process for use as an electroacupuncture device to stimulate appropriate auricular acupuncture points.  These include but are not limited to the P-Stim™ and E-pulse™.

I.    Needle Acupuncture: Initial Therapy

Needle acupuncture (manual or electroacupuncture) may be considered MEDICALLY NECESSARY AND APPROPRIATE for the following indications:

• Treatment of chronic pain (defined as duration of at least six months) when the following criteria have been met, prior to the beginning of acupuncture treatment:
  • A comprehensive history and physical evaluation of the patient has been completed to document etiology of the pain; AND
  • Conservative forms of multidisciplinary therapy (e.g., pharmacologic therapy, physical therapy, psychotherapy) have been tried and have failed to alleviate the pain.
• Prevention and treatment of nausea associated with surgery, chemotherapy, or pregnancy.

II.   Needle Acupuncture: Maintenance Therapy

Needle acupuncture (manual or electroacupuncture) maintenance therapy may be considered MEDICALLY NECESSARY AND APPROPRIATE when: 

• Patient meets medical necessity criteria above; AND 
• Acupuncture treatment has resulted in positive clinical response demonstrated by one of the following: 
  • Decreased use of pain medication, OR 
  • Objectively measured improvement in function (e.g., Neck Disability Index, Oswestry Disability Index, Pain Disability Index, and Roland Morris Back Pain Disability Questionnaire); OR 
  • Improvement of function or stabilization of functional decline indicated by measures at the onset of acupuncture and measures at subsequent follow-up maintenance treatments.

Needle acupuncture (manual or electroacupuncture) maintenance therapy is considered NOT MEDICALLY NECESSARY AND APPROPRIATE in all other situations.

III.  Needle Acupuncture: Experimental/Investigative Uses

Needle acupuncture is considered EXPERIMENTAL/INVESTIGATIVE for all other conditions including but not limited to the following due a lack of clinical evidence demonstrating an impact on improved health outcomes:

• Substance-related disorders
• Behavioral health conditions
• Infertility
• Obesity/weight loss
• Fatigue
• Allergic rhinitis
• Asthma
• Acne
• Sexual dysfunction
• Nausea due to conditions other than surgery, pregnancy or chemotherapy

IV.   Electrical Stimulation of Auricular Acupuncture Points: Experimental/Investigative Uses

Electrical stimulation of auricular acupuncture points is considered EXPERIMENTAL/INVESTIGATIVE due to a lack of evidence demonstrating an impact on improved health outcomes.

Documentation Submission

Documentation supporting the medical necessity criteria described in the policy for maintenance therapy must be included in the prior authorization, when prior authorization is required. In addition, the following documentation must also be submitted:

• Clinical notes describing the following:
  1. Patient meets medical necessity criteria for initial acupuncture treatment
  2. Description of current treatment plan and outcomes including one of the following:
     • Decreased use of pain medication, OR
     • Objectively measured improvement in function, function (e.g., Neck Disability Index, Oswestry Disability Index, Headache Index, Roland Morris, Promo6b Pain Index); OR
     • Stabilization of functional decline Stabilization of functional decline demonstrated valid and reliable functional measures with return maintenance visits to support functional declines and improvement with an initial trial of acupuncture and subsequent follow up maintenance treatments.

Link to Pre-Authorization Form:  https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf