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Prior Authorization Review Panel

MCO Policy Submission

A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.

Plan: AmeriHealth Caritas Northeast

Submission Date: April 29, 2019

Policy Number: CCP.1155

Effective Date: April 1, 2015 Revision Date: April 2, 2019

Policy Name: Acupuncture Type of Submission – Check all that apply: New Policy Revised Policy* Annual Review – No Revisions *All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below: Please see revisions below using tracked changes. Name of Authorized Individual (Please type or print): William D. Burnham, MD

Signature of Authorized Individual:

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Clinical Policy Title: Acupuncture Clinical Policy Number: CCP.1155 Effective Date: April 1, 2015 Initial Review Date: January 21, 2015 Most Recent Review Date: April 2, 2019 Next Review Date: February 2020 Related policies:

None. ABOUT THIS POLICY: AmeriHealth Caritas Northeast has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas Northeast’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas Northeast when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas Northeast’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas Northeast’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas Northeast will update its clinical policies as necessary. AmeriHealth Caritas Northeast’s clinical policies are not guarantees of payment.

Coverage policy AmeriHealth Caritas Northeast considers the use of acupuncture to be clinically proven and, therefore, medically necessary when performed by a qualified practitioner who is appropriately trained and licensed in acupuncture and when all the following criteria are met:

• For patients age 18 years or older: • Patient needs treatment for one of the following medical conditions:

- Chemotherapy-induced or postoperative nausea and vomiting (Cheong, 2013; Garcia, 2013; Lau, 2016; Lee, 2015).

- Acute, subacute, or chronic (lasting more than three months) non-specific lower back pain (Qaseem, 2017).

- Chronic migraine (Linde, 2009, 2016b). - Chronic pain caused by osteoarthritis of the knee (Hochberg, 2012; Manyanga,

2014; Vickers, 2017; Zhang, 2017).

Policy contains: • Chronic migraine. • Knee osteoarthritis. • Low back pain. • Nausea and vomiting. • Temporomandibular disorders.

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- Temporomandibular disorders (Fernandes, 2017; Gil-Martínez, 2018; Wu, 2017). • As adjunctive treatment when either of the following conditions applies:

- Other standard treatment options inadequately control symptoms. - Patient refuses treatment or experiences adverse effects from such treatment.

Limitations: All other uses of acupuncture are not medically necessary. Please note:

• Maintenance treatment, when the member’s symptoms are neither regressing nor improving, is not medically necessary.

• For chronic tension-type headaches in youth over 12 years old, up to 10 sessions of acupuncture over 5—8 weeks may be provided.

• Children should not be treated with acupuncture for nausea and vomiting while under anesthesia.

• Treatments beyond five visits without meaningful improvement in symptoms require review by a medical director.

For Medicare members only: AmeriHealth Caritas Northeast considers the use of acupuncture to be investigational and, therefore, not medically necessary. Alternative covered services: Standard medical management of chronic pain syndromes or nausea and vomiting due to chemotherapy or anesthesia. Background Acupuncture is one of the practices of traditional Chinese medicine, which considers energy known as “qi” to flow throughout the body along patterns known as meridians (National Center for Complementary and Integrative Health, 2014). Disturbances in the flow of qi are believed to result in disease. Acupuncture is based on the theory that stimulating specific points on the body corrects imbalances in the flow of qi, thereby improving health. The approach has four components:

• Acupuncture needle(s). • Target location mapped by traditional Chinese medicine. • Depth of needle insertion. • Stimulation of the inserted needle.

Traditional acupuncture uses thin needles, but it may also apply manual pressure, electrical stimulation, magnets, low-power lasers, heat, and ultrasound. The U.S. Food and Drug Administration regulates

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acupuncture needles as Class II medical devices with special controls. Acupuncture needles must be labeled for single use only, biocompatible and sterile, and administered by qualified practitioners only (21CFR880.5580). The professional credentials of an acupuncture practitioner can range from none to licensed medical doctor. Licensure laws and scope-of-practice guidelines regulating acupuncture practitioners vary by state. Currently, 22 states require the passage of National Certification Commission for Acupuncture and Oriental Medicine examinations, and 21 states and the District of Columbia specify National Certification Commission for Acupuncture and Oriental Medicine certification as a prerequisite for licensure (2018). Board certification in medical acupuncture is granted by the American Board of Medical Acupuncture (2019). Certification entails:

• Meeting minimum general requirements. • Meeting education and training requirements. • Meeting experience requirements. • Successfully passing the American Board of Medical Acupuncture examination.

Searches AmeriHealth Caritas Northeast searched PubMed and the databases of:

• UK National Health Services Centre for Reviews and Dissemination. • Agency for Healthcare Research and Quality. • The Centers for Medicare & Medicaid Services.

We conducted searches on November 27, 2018. Search terms were: “acupuncture” (MeSH) and “acupuncture therapy” (MeSH), as well as free text “acupuncture” for articles published in English. We included:

• Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

• Guidelines based on systematic reviews. • Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple

cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies — which also rank near the top of evidence hierarchies.

Findings Given the substantial volume of literature on this topic, AmeriHealth Caritas Northeast considered only the most comprehensive systematic reviews of acupuncture published in the last five years. More than

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100 systematic reviews and meta-analyses were identified, the majority of which found evidence for various clinical uses of acupuncture to be of low quality. Conflicting results were also evident. An evidence map of acupuncture (not a formal systematic review) produced for the Veterans Health Administration, which identified 183 systematic reviews published since 2005, found inconsistency in the quality and findings of systematic reviews (Hempel, 2014). Inconsistency in results appeared to be related to the selection of the comparator to which the treatment effects of acupuncture were compared. Controls included no treatment, waiting list assignment, acupuncture as add-on treatment to a treatment plan received by both treatment groups, placebo control (such as sham acupuncture), and active controls, such as exercise and usual care. Typically, trials included a placebo arm and a no-treatment arm to explore variations in the impact of the different types of placebo. There is currently no universal standard for what constitutes an appropriate method or procedure for a sham acupuncture control, and this may contribute to the discrepancy between observed clinical effectiveness of acupuncture and the lack of rigorous research supporting these observations for many indications. Therefore, this policy will focus on those indications for which there is high-quality and consistent evidence demonstrating improvement in health outcomes with acupuncture. Nine systematic reviews are listed in the summary table. Eight evidence-based guidelines and two economic analyses pertaining to the topics of these syntheses were identified. There is sufficient evidence to support the use of acupuncture as adjunctive treatment for certain types of chronic pain and nausea and vomiting. Included were individual syntheses for the following indications:

• Postoperative- or chemotherapy-induced nausea and vomiting. • Chronic non-specific low back pain. • Chronic migraine. • Osteoarthritis of the knee.

The benefits of acupuncture are limited mostly to immediate and short-term post-treatment periods in patients ages 18 and older using sham or no-acupuncture controls. Evidence of its effectiveness over other conventional treatment modalities is conflicting or of low quality. Evidence-based guidelines listed in the references recommend acupuncture as an adjunct to standard treatment for the specific indications listed, when other treatment options inadequately control symptoms, or when patients refuse treatment or experience adverse effects from such treatment. One guideline did not recommend acupuncture for the management of osteoarthritis of the knee (Jevsevar, 2013). While acupuncture is generally a safe procedure, reporting of harms was poor across studies, so a comparison of the rate of adverse events between acupuncture and other treatments cannot be made. When performed by an appropriately trained practitioner using clean technique and single-use needles, reported adverse events were generally localized, minor, transient, and infrequent. When acupuncture is not delivered properly, it may result in serious adverse effects. These include infections, punctured

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organs, collapsed lungs, injury to the central nervous system, and even death (Ernst, 2011; National Center for Complementary and Integrative Health, 2016).

• There is insufficient evidence to draw conclusions regarding the optimal frequency of

administration, duration of each session, number, depth of needle penetration, or needle location.

• There is insufficient evidence to support the cost-effectiveness of acupuncture for any indication. The few cost-effectiveness analyses that have been conducted in the United States found either a lack of effectiveness or sufficient rigor needed to further inform practice (Kim, 2012; Pinto, 2012).

Policy updates: In the 2016 update, we identified 26 new systematic reviews and meta-analyses and one new clinical practice guideline published in the last year. Seven systematic reviews and meta-analyses reported significant short-term or intermediate-term positive effects of acupuncture treatment for several conditions, but significant study design flaws and small numbers of studies limited the validity of the evidence included in these analyses (Chan, 2015; Dong, 2015; Feng, 2015; Gutke, 2015; Law, 2015; Yuan, 2015; Zhou, 2015). One clinical practice guideline stated acupuncture could be a non-pharmacologic option for allergic rhinitis based on moderate evidence from two large randomized controlled trials reporting improvement in symptoms and quality of life with acupuncture, but stopped short of issuing a firm recommendation for its use (Seidman, 2015). The new information would not alter the conclusions of the original policy. Therefore, no changes to the policy were warranted. In the 2017 update, we identified 15 new systematic reviews and meta-analyses and one new evidence-based guideline for this policy. New evidence confirmed previous policy findings of acupuncture’s safety and efficacy in tension-type headache (Linde, 2016a), migraine (Linde, 2016b), and palliation of chemotherapy-induced nausea and vomiting (Lau, 2016), as well as insufficient demonstration of safety and efficacy in chronic pain syndromes (Qin, 2016), and post-operative pain (Wu, 2016). The results of several systematic reviews and meta-analyses suggested acupuncture had a limited treatment effect on a number of new clinical indications, but the evidence of safety and efficacy was inconclusive due to poor methodological quality, insufficient quantity, or conflicting findings (Cui, 2016; del Pino-Sedeno, 2016; He, 2016; Kim, 2016; Lim, 2016; Mangese, 2016; Smith, 2016; Su, 2016; Van den Heuvel, 2016; Yang, 2016). A guideline by the American College of Physicians on treatments (including acupuncture) for major depressive disorder in adults issued strong evidence-based recommendations for cognitive behavioral therapy and antidepressants, but made no specific recommendation for acupuncture (Qaseem, 2016). The new information did not change the original findings. Therefore, no policy changes were warranted. In the 2018 update, we added five guidelines and five peer-reviewed articles to the reference list. Of these, we added three publications to the table of evidence. A guideline developed by the American

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College of Physicians (Qaseem, 2017) on noninvasive treatments for lower back pain issued strong recommendations for acupuncture as a nonpharmacologic treatment for acute or subacute lower back pain based on low-quality evidence, and for chronic lower back pain based on moderate quality evidence. With this recommendation, we have added acupuncture for acute or subacute lower back pain to the policy. In other published guidelines, reviews found insufficient evidence to support or refute the use of acupuncture for restless leg syndrome (Winkelman, 2016) or to support the use of acupuncture for post-traumatic stress disorder (Management of Posttraumatic Stress Disorder Work Group, 2017). Acupuncture is not recommended for eating disorders (National Institute for Health and Care Excellence, 2017). Two meta-analyses support the use of acupuncture in Parkinson’s disease (Lee, 2017; Liu, 2017). In 2019, the policy ID changed from 03.02.03 to CCP.1155. We added five professional society guidelines and nine peer-reviewed publications to the policy. Regarding adult care, one systematic review (Fernandes, 2017), one meta-analysis (Wu, 2017), and one review article (Gil-Martínez, 2018) support acupuncture as a treatment for the chronic pain associated with temporomandibular disorders. Although much of the data examined feature small sample sizes and short-term follow-up periods (e.g., 12 weeks), these studies demonstrate that conventional acupuncture results in statistically significant pain reduction, especially in those with myofascial pain. Therefore, “temporomandibular disorders” has been added to the list of indications covered by this policy. Regarding pediatric care, there have been fewer studies of acupuncture in children compared to the body of research among adults. Acupuncture appears to result in few adverse effects in children when performed by a qualified practitioner. In some conditions, it may be used to decrease the use of prescription medication. Brittner’s (2016) systematic review found that the strongest body of evidence for the efficacy and safety of acupuncture in pediatric populations at that time was for headache, migraine, and postoperative pain. Brittner’s view was that acupuncture may be considered for nausea and vomiting, but not while children are under anesthesia, when it is less effective. Lee’s (2015) Cochrane review on the topic of wrist acupuncture (using the point PC6) for postoperative nausea and vomiting found a moderate effect size for both children and adults, to the extent that further sham studies to confirm this benefit were deemed unnecessary. For chronic tension-type headaches in youth over 12 years old, up to 10 sessions of acupuncture over 5—8 weeks may be considered (National Institute of Health and Care Excellence, 2015). The American Academy of Pediatrics published a policy article (McClafferty, 2017) on the topic of integrative medicine that included a section on acupuncture summarizing the above findings. A systematic review of 24 systematic reviews found promising evidence for the efficacy of acupuncture for several other uses in children, including pain conditions, nocturnal enuresis, tic disorders, amblyopia, and cerebral palsy, however, only six of the included studies were deemed to be of high quality, sample sizes were small, most included studies lacked data on safety and adverse events, and a quantitative analysis could not be performed due to heterogeneity (Yang, 2015).

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Adams (2011) identified 279 adverse events in 1422 pediatric patients, some of whom experienced more than one event. These included 25 serious adverse events consisting of thumb deformity (12), infections (5), one incident each of cardiac rupture, pneumothorax, nerve impairment, subarachnoid hemorrhage, intestinal obstruction, hemoptysis, reversible coma, and overnight hospitalization, and one moderate effect (infection). Adams calculated a mild adverse effect incidence per patient of 168 in 1422 patients (11.8 percent, 95 percent confidence interval 10.1-13.5). Yang (2015) noted that some developmental issues, such as open fontanel in infants, leaves them vulnerable to use of needles in the affected region. With the above evidence, we are adding acupuncture for use in treatment of pediatric headache, migraine, postoperative nausea and vomiting, and postoperative pain to the coverage policy. References Professional society guidelines/other: American Board of Medical Acupuncture, Inc. Requirements for certification in medical acupuncture. 2009. http://www.dabma.org/requirements.asp. Accessed February 7, 2019. American Society of Anesthesiologists Task Force on Chronic Pain Management; American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010; 112(4): 810-833. Doi: 10.1097/ALN.0b013e3181c43103. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1932775. Accessed February 7, 2019. Deng GE, Rausch SM, Jones LW, et al. Complementary therapies and integrative medicine in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e420S-436S. Doi: 10.1378/chest.12-2364. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118(1):85-113. Doi: 10.1213/ANE.0000000000000002. Knee disorders. In: Hegmann K, ed. Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2011:1-503. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012; 64(4): 465-474. Doi: 10.1002/acr.21596.

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Jevsevar DS, Brown GA, Jones DL, et al. The American Academy of Orthopaedic Surgeons evidence-based guideline on: treatment of osteoarthritis of the knee 2nd edition. J Bone Joint Surg Am. 2013; 95(20): 1885-1886. https://www.aaos.org/cc_files/aaosorg/research/guidelines/treatmentofosteoarthritisofthekneeguideline.pdf. Accessed February 6, 2019. Management of Posttraumatic Stress Disorder Work Group. VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. Version 3.0. Washington (DC): Department of Veterans Affairs, Department of Defense; 2017 Jun. Full guideline: https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal082917.pdf. Clinician summary: https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGClinicianSummaryFinal.pdf. Accessed February 6, 2019. McClafferty H, Vohra S, Bailey M, et al. Pediatric integrative medicine. Pediatrics. 2017; 140(3): e20171961; Doi: 10.1542/peds.2017-1961. National Center for Complementary and Integrative Health. Acupuncture: in depth. National Center for Complementary and Integrative Health (NCCIH). National Center for Complementary and Integrative Health website. https://nccih.nih.gov/health/acupuncture/introduction. Accessed February 7, 2019. National Certification Commission of Acupuncture and Oriental Medicine. State licensure requirements interactive map. Updated January 1, 2018. https://www.nccaom.org/state-licensure/. Accessed February 7, 2019. National Institute for Health and Care Excellence. Eating disorders: recognition and treatment. NICE guideline 69. May 23, 2017. https://www.nice.org.uk/guidance/ng69. Accessed February 6, 2019. National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. NICE clinical guideline 150. Updated November 25, 2015. http://www.nice.org.uk/guidance/cg150. Accessed February 6, 2019. Qaseem A, Barry MJ, Kansagara D. Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016; 164(5): 350-359. Doi: 10.7326/M15-2570. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-30. Doi: 10.7326/M16-2367.

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Dong W, Goost H, Lin XB, et al. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. Medicine (Baltimore). 2015; 94(10): e510. Doi: 10.1097/MD.0000000000000510. Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011; 152(4): 755-764. Doi: 10.1016/j.pain.2010.11.004. Feng S, Han M, Fan Y, et al. Acupuncture for the treatment of allergic rhinitis: A systematic review and meta-analysis. Am J Rhinol Allergy. 2015; 29(1): 57-62. Doi: 10.2500/ajra.2015.29.4116. Fernandes AC, Duarte Moura DM, Da Silva LGD, De Almeida EO, Barbosa GAS. Acupuncture in temporomandibular disorder myofascial pain treatment: a systematic review. J Oral Facial Pain Headache. 2017;31(3):225-232. Doi: 10.11607/ofph.1719. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med. 2012; 2012: 953139. Doi: 10.1155/2012/953139. Garcia MK, McQuade J, Haddad R, et al. Systematic review of acupuncture in cancer care: a synthesis of the evidence. J Clin Oncol. 2013; 31(7): 952-960. Doi: 10.1200/JCO.2012.43.5818. Gil-Martínez A, Paris-Alemany A, López-de-Uralde-Villanueva I, La Touche R. Management of pain in patients with temporomandibular disorder (TMD): challenges and solutions. J Pain Res. 2018;11:571-587. Doi:10.2147/JPR.S127950 Gutke A, Betten C, Degerskar K, Pousette S, Olsen MF. Treatments for pregnancy-related lumbopelvic pain: a systematic review of physiotherapy modalities. Acta Obstet Gynecol Scand. 2015; 94(11): 1156-1167. Doi: 10.1111/aogs.12681. He M, Li X, Liu Y, et al. Electroacupuncture for Tinnitus: A systematic review. PLoS One. 2016; 11(3): e0150600. Doi: 10.1371/journal.pone.0150600. Hempel S, Taylor SL, Solloway MR, et al. Evidence Map of Acupuncture [Internet] . Washington, D.C. Department of Veterans Affairs; 2014 January. VA-ESP Project #05-226; 2013. https://www.ncbi.nlm.nih.gov/books/NBK185071/. Accessed February 6, 2019. Hutchinson AJ, Ball S, Andrews JC, Jones GG. The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature. J Orthop Surg Res. 2012; 7: 36. Doi: 10.1186/1749-799X-7-36. Jo J, Lee YJ, Lee H. Acupuncture for polycystic ovarian syndrome: A systematic review and meta-analysis. Enix. D, ed. Medicine. 2017;96(23):e7066. Doi:10.1097/MD.0000000000007066.

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Kim KH, Lee MS, Kim TH, et al. Acupuncture and related interventions for symptoms of chronic kidney disease. Cochrane Database Syst Rev. 2016; (6): Cd009440. Doi: 10.1002/14651858.CD009440.pub2. Kim SY, Lee H, Chae Y, Park HJ, Lee H. A systematic review of cost-effectiveness analyses alongside randomized controlled trials of acupuncture. Acupunct Med. 2012; 30(4):273-285. Doi: 10.1136/acupmed-2012-010178. Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: A systematic review and meta-analysis. Spine. 2013; 38(24): 2124 – 2138. Doi: 10.1097/01.brs.0000435025.65564.b7. Lau CH, Wu X, Chung VC, et al. Acupuncture and related therapies for symptom management in palliative cancer care: Systematic review and meta-analysis. Medicine. 2016; 95(9): e2901. Doi: 10.1097/MD.0000000000002901. Law D, McDonough S, Bleakley C, Baxter GD, Tumilty S. Laser acupuncture for treating musculoskeletal pain: a systematic review with meta-analysis. J Acupunct Meridian Stud. 2015; 8(1): 2-16. Doi: 10.1016/j.jams.2014.06.015. Lee A, Chan SK, Fan LT. Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2015;11(11):CD003281. Doi: 10.1002/14651858.CD003281.pub4 Lee MS, Ernst E. Acupuncture for pain: an overview of Cochrane reviews. Chin J Integr Med. 2011; 17(3):187-189. Doi: 10.1007/s11655-011-0665-7. Lim CE, Ng RW, Xu K, et al. Acupuncture for polycystic ovarian syndrome. Cochrane Database Syst Rev. 2016; (5): Cd007689. Doi: 10.1002/14651858.CD007689.pub3. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016a; 4: Cd007587.(a) Doi: 10.1002/14651858.CD007587.pub2. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016b; 6: Cd001218.(b). Doi: 10.1002/14651858.CD007587.pub2. Lee S-H, Lim S. Clinical effectiveness of acupuncture on Parkinson disease: A PRISMA-compliant systematic review and meta-analysis. Pany. S, ed. Medicine. 2017;96(3):e5836. Doi:10.1097/MD.0000000000005836. Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015; 9: CD001139. Doi: 10.1002/14651858.CD001139.pub4.

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Liu H, Chen L, Zhang Z, et al. Effectiveness and safety of acupuncture combined with Madopar for Parkinson’s disease: a systematic review with meta-analysis. Acupunct Med. 2017;35:404-412. Doi: 10.1136/acupmed-2016-011342. Mangesi L, Zakarija-Grkovic I. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev. 2016; (6): Cd006946. Doi: 10.1002/14651858.CD006946.pub3. Manyanga T, Froese M, Zarychanski R, et al. Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis. BMC Complement Altern Med. 2014; 14: 312. Doi: 10.1186/1472-6882-14-312. Pennick V, Liddle SD. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev. 2013; 8: Cd001139. Doi: 10.1002/14651858.CD001139.pub3. Pinto D, Robertson MC, Hansen P, Abbott JH. Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review. Value Health. 2012; 15(1): 1-12. Doi: 10.1016/j.jval.2011.09.003. Qin Z, Wu J, Zhou J, Liu Z. Systematic review of acupuncture for chronic prostatitis/chronic pelvic pain syndrome. Medicine. 2016; 95(11): e3095. Doi: 10.1097/MD.0000000000003095. Smith CA, Armour M, Zhu X, et al. Acupuncture for dysmenorrhoea. Cochrane Database Syst Rev. 2016; 4: Cd007854. Doi: 10.1002/14651858.CD007854.pub3. Su L, Meng L, Chen R, et al. Acupoint application for asthma therapy in adults: A systematic review and meta-analysis of randomized controlled trials. Forsch Komplementmed. 2016; 23(1): 16-21. Doi: 10.1159/000443813. Van den Heuvel E, Goossens M, Vanderhaegen H, Sun HX, Buntinx F. Effect of acustimulation on nausea and vomiting and on hyperemesis in pregnancy: a systematic review of Western and Chinese literature. BMC Complement Altern Med. 2016; 16: 13. Doi: 10.1186/s12906-016-0985-4. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012; 172(19): 1444 – 1453. Doi: 10.1001/archinternmed.2012.3654. Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: Update of an individual; patient data meta-analysis. J Pain. 2017; pii: S1526-5900(17)30780-0. Doi: 10.1016/j.jpain.2017.11.005. Wu JY, Zhang C, Xu YP, et al. Acupuncture therapy in the management of the clinical outcomes for temporomandibular disorders: A PRISMA-compliant meta-analysis. Medicine. 2017;96(9):e6064. Doi: 10.1097/md.0000000000006064.

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Wu MS, Chen KH, Chen IF, et al. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016; 11(3): e0150367. Doi: 10.1371/journal.pone.0150367. Yang A, Wu HM, Tang JL, et al. Acupuncture for stroke rehabilitation. Cochrane Database Syst Rev. 2016; (8): Cd004131. Doi: 10.1002/14651858.CD004131.pub3. Yang C, Hao Z, Zhang LL, Guo Q. Efficacy and safety of acupuncture in children: an overview of systematic reviews. Pediatr Res. 2015;78(2):112–119. Doi: 10.1038/pr.2015.91. Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese medicine for neck pain and low back pain: a systematic review and meta-analysis. PLoS One. 2015; 10(2): e0117146. Doi: 10.1371/journal.pone.0117146. Zhang Q, Yue J, Golianu B, Sun Z, Lu Y. Updated systematic review and meta-analysis of acupuncture for chronic knee pain. Acupunct Med. 2017;35(6):392-403. Doi: 10.1136/acupmed-2016-011306. Zhou J, Peng W, Xu M, Li W, Liu Z. The effectiveness and safety of acupuncture for patients with Alzheimer disease: a systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2015; 94(22): e933. Doi: 10.1097/MD.0000000000000933. Centers for Medicare and Medicaid Services National Coverage Determinations: 30.3 Acupuncture. 30.3.1 Acupuncture for Fibromyalgia. 30.3.2 Acupuncture for Osteoarthritis. 10.3 Inpatient Hospital Pain Rehabilitation Programs. 10.4 Outpatient Hospital Pain Rehabilitation Programs. Local Coverage Determinations: A55240 Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device). Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly.

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CPT Code Description Comments

97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 14 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 re-insertion of needle(s)

97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 14 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 re-insertion of needle(s)

ICD-10 Code Description Comments G43.01-G43.919 Migraine G43.701-G43.719 Chronic migraine G89.12 Acute postprocedural thoracotomy pain G89.18 Other acute postprocedural pain G89.22 Chronic postprocedural thoracotomy pain G89.28 Other chronic postprocedural pain G89.29 Other chronic pain G89.0 Central pain syndrome G89.4 Chronic pain syndrome M17.0-M17.9 Osteoarthritis - knee M25.561-M25,569 Pain in knee M26.201-M26.69 Temporomandibular joint disorders M54.40-M54.5 Lower back pain R11.0-R11.2 Nausea and vomiting R51 Headache T45.1X5 Adverse effect of antineoplastic and immunosuppressive drugs T80.89X Other complications following infusion, transfusion or therapeutic injection Z92.21 Personal history of antineoplastic chemotherapy HCPCS Level II Code Description Comments

S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-hyphenon-hyphenone contact with the patient