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:
II. Needle Acupuncture: Maintenance Therapy
Needle acupuncture (manual or electroacupuncture) maintenance therapy may be considered MEDICALLY NECESSARY AND APPROPRIATE when:
Needle acupuncture (manual or electroacupuncture) maintenance therapy is considered NOT MEDICALLY NECESSARY 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:
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.
0783T 97810 97811 97813 97814 S8930
Documentation Submission
Documentation supporting the medical necessity criteria described in the policy for maintenance therapy must be included. In addition, the following documentation must also be submitted:
Link to Pre-Authorization Form: https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf
No additional statements.
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Acknowledgements:
CPT® codes copyright American Medical Association® 2023. All rights reserved.
CDT codes copyright American Dental Association® 2023. All rights reserved.
