BlueCross and BlueShield of Montana Medical Policy/Codes
Acupuncture
Chapter: Surgery: Procedures
Current Effective Date: October 25, 2013
Original Effective Date: October 25, 2013
Publish Date: October 25, 2013
Description

Acupuncture is an ancient method of healing originating from Chinese traditional medicine. It consists of the insertion of needles into the body at specific points that are believed to be effective in the treatment of specific health problems. Acupuncture has been used to:

  • Induce anesthesia,
  • Relieve pain,
  • Alleviate withdrawal symptoms of substance abusers,
  • Treat various non-painful disorders.

In 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. Acupuncture has four 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.

Electroacupuncture refers to the attachment of wires to acupuncture needles to provide low voltage electrical energy. This electrical energy is a substitute for the manual tweedling (e.g. turning, twisting) of standard acupuncture. (Electroacupuncture is sometimes referred to as transcutaneous electrical nerve stimulation acupuncture or TENS acupuncture.)

Laser acupuncture is a relatively new form of acupuncture. This consists of a low-level laser beam applied to specific points of the body, which is said to control symptoms by stimulating the release of endorphins. Uses of laser acupuncture include treatment for cessation of smoking, appetite control and weight loss, and stress and relaxation.

Auricular electrostimulation involves the stimulation of acupuncture points on the ear. Devices have been developed that provide electrical stimulation to auricular acupuncture sites over a period of several days. One device, the P-Stim™, is a single-use miniature electrical stimulator for auricular acupuncture points that is worn behind the ear with a self-adhesive electrode patch. A selection stylus that measures electrical resistance is used to identify 3 auricular acupuncture points. The P-Stim™ device connects to 3 inserted acupuncture needles with caps and wires. The device is pre-programmed to be on for 180 minutes, then off for 180 minutes. The maximum battery life of this single-use device is 96 hours.

Dry needling (also called Western acupuncture, or medical acupuncture) is a relatively new technique in which a dry needle, or acupuncture needle, is inserted directly into a myofascial trigger point to treat pain. (Kalichman, 2010) Dry needling is being done by both acupuncturists and physical therapists. In their 2011 Position Paper on Dry Needling, the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) states that dry needling is an acupuncture technique, regardless of the language used to describe the technique, and that dry needling has been used synonymously with trigger point dry needling;  manual trigger point therapy, when using dry needling; intramuscular dry needling; intramuscular manual therapy, when using dry needling; and intramuscular stimulation, when using dry needling. 

Regulatory Status

The U.S. Food and Drug Administration (FDA) has cleared acupuncture needles for marketing. The needles used in acupuncture, when intended for general use in “the performance of acupuncture,” have been classified by the FDA to Class II devices (The Gray Sheet, April 8, 1996). The order states that “clinical studies and preclinical animal studies constitute valid scientific evidence in support of the clinical effectiveness of acupuncture needles for the performance of acupuncture treatment.”

The P-Stim™ (NeuroScience Therapy Corp) received marketing clearance through the FDA’s 510(k) process in 2006. The P-Stim™ is intended for use as an electro-acupuncture device to stimulate appropriate auricular acupuncture points. The E-pulse (AMM Marketing LLC) received 510(k) marketing clearance in 2009, listing the P-Stim™ as a predicate device. The E-pulse is a microprocessor-controlled battery-powered unit designed to administer auricular point nerve stimulation treatment for pain therapy over a 96-hour period.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Acupuncture in any form including, but not limited to the following methods, is considered experimental, investigational and unproven:

  • Acupuncture; or
  • Electroacupuncture; or
  • Stimulation of acupuncture points using transcutaneous electrical stimulation; or
  • Laser acupuncture using low-level laser therapy (LLLT). Uses of laser acupuncture include, but are not limited to, smoking cessation, appetite control, weight loss, stress and relaxation;
  • Auricular electrostimulation (electrical stimulation of auricular acupuncture points);
  • Dry needling, including dry needling of myofascial trigger points.

Rationale

This policy was originally based on a 1996 Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessment of acupuncture for the treatment of pain. The evidence did not clearly show that the effects of acupuncture exceed placebo effects. A recent MEDLINE search through April of 2007 does not show consistent results for acupuncture, electroacupuncture, or laser acupuncture. In current literature, most physicians continue to be skeptical about certain treatments, citing a lack of clinical information. Before there is widespread acceptance of acupuncture in the conventional medical establishment, more clinical research needs to be provided in a teaching hospital environment.

2012 Update

Auricular Electrical Stimulation

In 2004, Sator-Katzenschlager et al. reported a randomized double-blind controlled study of auricular electro-acupuncture compared to conventional manual auricular acupuncture in 61 patients with chronic low back pain (duration of at least 6 months). All needles were connected to the P-Stim device; in the control group, devices were applied without electrical stimulation. Treatment was performed once weekly for 6 weeks, with needles withdrawn 48 hours after insertion. Patients received questionnaires assessing pain intensity and quality, psychological well-being, activity level, and quality of sleep using visual analog scale (VAS). There was a significant improvement in pain at up to 18 weeks’ follow-up. Auricular electro-acupuncture resulted in greater improvement in the outcome measures than that of the control group. For example, at 18-week follow-up, VAS pain intensity was less than 5 in the control group and less than 2 in the electro-acupuncture. This study is limited by the small number of participants. In 2003, Sator-Katzenschlager et al. had reported similar effects in a small randomized study of 21 patients with chronic cervical pain.

In a 2008 European study, Bernateck et al. reported the use of the P-Stim device in a randomized controlled trial (RCT) of 44 patients with rheumatoid arthritis. The control group received autogenic training, a psychological intervention in which participants learn to relax their limbs, breathing, and heart. Electro-acupuncture (continuous stimulation for 48 hours at home) and lessons in autogenic training were performed once weekly for 6 weeks. In addition, the control patients were encouraged to use an audiotape to practice autogenic training every day. The needles and devices were removed after 48 hours. Seven patients withdrew from the study before beginning the intervention; the 37 remaining patients completed the study through 3 months of follow-up. The primary outcome measures were the mean weekly pain intensity and the disease activity score (DAS-28). At the end of treatment and at 3-month follow-up, a statistically significant improvement was observed in all outcome measures for both groups. There was greater improvement in the electro-acupuncture group than the control group (e.g., VAS pain 2.79 vs. 3.95) during the treatment period. This difference did not persist at the 3-month follow-up. The clinical significance of a 1-point difference in VAS from this small trial is unclear.

In a 2007 review, Sator-Katzenschlager and Michalek-Suberer found that studies on the use of the P-Stim in acute pain (e.g., oocyte aspiration and molar tooth extraction) are contradictory. A 2011 randomized trial from Europe tested the efficacy of the P-Stim in 40 female patients undergoing gynecologic surgery. Patients were randomly assigned to receive auricular acupuncture or sham stimulation. Patients in the control group received electrodes without needles and the P-Stim devices were applied without electrical stimulation. The P-Stim device was placed behind the ear at the end of the operation on all patients while they were still under general anesthesia, and the dominant ear was completely covered with identical dressing in both groups to maintain blinding. Postoperatively, patients received 1,000 mg paracetamol every 6 hours, with additional piritramide given on demand. Needles and devices were removed 72 hours postoperatively. A blinded observer found no significant difference between the 2 groups in consumption of piritramide during the first 72 hours postoperatively (acupuncture vs. placebo: 15.3 mg vs. 13.9 mg, respectively) or on VAS scores taken at 0, 2, 24, 48, and 72 hours (average of 2.32 vs. 2.62, acupuncture vs. placebo, respectively)

Dry Needling

In a 2009, Tough et al. conducted a meta-analysis to establish whether there is evidence for or against the efficacy of dry needling as a treatment approach for myofascial trigger point pain. Twenty-three papers were included. The authors concluded that the hypothesis that needling therapies have efficacy beyond placebo was neither supported nor refuted by the evidence from clinical trials. Controlled trials are needed to investigate whether needling has an effect beyond placebo for myofascial trigger point pain.

A 2010 by Cotchett et al. reviewed 3 quasi-experimental trials of dry needling for plantar fasciitis. The authors concluded that the poor quality and heterogenous nature of the studies precluded definitive conclusions, and highlighted the need for future trials to use rigorous randomized controlled methodology with measures such as blinding.

A 2011 Cochrane Review was done by Furlan to assess the effects of acupuncture and dry needling for the treatment of nonspecific low back pain. The review included 23 clinical trials. Furlan concluded that the data do not allow firm conclusions regarding effectiveness of acupuncture for low back pain. While the data suggested acupuncture and dry needling may be useful adjuncts to other therapies, most of the studies were of lower methodologic quality, and there is a clear need for higher quality studies in this area.   

Summary

No new clinical trial publications or any additional information was identified that would change the coverage position of this medical policy. Further, higher quality trials are needed to evaluate the efficacy of dry needling. In addition, the evidence available at this time is insufficient to evaluate the effect of auricular electrostimulation on health outcomes, including acute and chronic pain. Additional randomized studies with a larger number of subjects are needed to evaluate the efficacy of this treatment approach. Therefore, both auricular electrostimulation and dry needling are considered experimental, investigational and unproven.

Coding

Disclaimer for coding information on Medical Policies          

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes
99.91, 99.92.  Experimental, investigational and unproven for all diagnoses.
ICD-10 Codes

8E0H300, 8E0H30Z.  Experimental, investigational and unproven for all diagnoses.

Procedural Codes: 97810, 97811, 97813, 97814, S8948, S8930
References
  1. CMS—National Coverage Determination for Acupuncture for Osteoarthritis(30.3). (1980 May) Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov (Accessed on 2007 August 8).
  2. CMS—National Coverage Determination for Acupuncture (30.3). (1980 May) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (Accessed on 2007 August 8).
  3. Acupuncture, A Review. Regional Anesthesia (1996 July-August) 21(4):361-70.
  4. Acupuncture in the Treatment of Pain. Chicago, Illinois: Blue Cross Blue Shield Association  - Technology Evaluation Center Assessment Program (1997 January) 11(22):1-15.
  5. White, A.R., Rampes, H., et al. Acupuncture for smoking Cessation. Cochrane Database Systematic Review (2002) (2):CD000009.
  6. Yiming, C., Changix, Z., et al. Laser Acupuncture for Adolescent Smokers—a Randomized Double-Blind Controlled Trial. American Journal Chinese Medicine. (2000) 28-(3-4):443-9.
  7. Greif, R., Lasiny, S., et al. Transcutaneous electrical stimulation of an auricular acupuncture point decreases anesthetic requirement. Anesthesiology (2002 February) 96(2):306-12.
  8. Acupuncture: theory, efficacy, and practice. Annals of Internal Medicine (2002 March 5):136(5):374-83.
  9. Ferrandez, Infante A., and O.L. Garcia. Effectiveness of acupuncture in the treatment of pain from osteoarthritis of the knee. Atencion Primaria (2002 December) 30(10):602-88; discussion 609-10.
  10. Traditional Chinese medicine. Medical Clinics of North America (2002 January) 86(1):63-73.
  11. Acupuncture outcomes, expectations, patient-provider relationship, and the placebo effect: implications for health promotion. American Journal of Public Health (2002 October) 92(10):1662-7.
  12. Acupuncture in the management of pain in labor. Acta Obstetricia et Gynecologica Scandinavica (2002 October) 81(10):943-8.
  13. Habek, D. New findings in acupuncture therapy. Lijecnicki Vjesnik (2002 October) 124(10):322-9.
  14. Is acupuncture safe? A systematic review of case reports. Alternative Therapies in Health and Medicine (2003 January-February) 9(1):72-83.
  15. Melchart, D., Thormaehlen, J., et al. Acupuncture versus placebo versus sumatriptan for early treatment of migraine attacks: a randomized controlled trial. Journal of Internal Medicine (2003 February) 253(2):181-8.
  16. Cantan, R., Milesi-Defrance N., et al. Bilateral pneumothorax and tamponade after acupuncture. Presse Medicale (2003 February 22) 32(7):311-2.
  17. Bigal, M.E., Krymchantowski, A.V., et al. New developments in migraine prophylaxes. Expert  Opinion in Pharmacotherapy (2003 April) 4(4):433-43.
  18. Garrison, N.M., Christakis, D.A., et al. Smoking Cessation Interventions for Adolescents: A Systematic Review. American Journal Preventive Medicine (2003 November) 25(4):363-7.
  19. Sator-Katzenschlager SM, Szeles JC, Scharbert G et al. Electrical stimulation of auricular acupuncture points is more effective than conventional manual auricular acupuncture in chronic cervical pain: a pilot study. Anesth Analg 2003; 97(5):1469-73.
  20. Sator-Katzenschlager SM, Scharbert G, Kozek-Langenecker SA et al. The short- and long-term benefit in chronic low back pain through adjuvant electrical versus manual auricular acupuncture. Anesth Analg 2004; 98(5):1359-64, table of contents.
  21. CMS—National Coverage Determination for Acupuncture (30.3). (2004 April) Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov (Accessed on 2007 August 8).
  22. Stop smoking today! Advanced Laser Solutions. Available at http://www.seniorsapprove.com (Accessed on 2005 April 18).
  23. Quit smoking laser therapy treatment. Freedom Laser Therapy, Inc. Available at http://www.freedomlasertherapy.com (Accessed on 2005 April 18). 
  24. Sator-Katzenschlager SM, Michalek-Sauberer A. P-Stim auricular electroacupuncture stimulation device for pain relief. Expert Rev Med Devices 2007; 4(1):23-32.
  25. Bernateck M, Becker M, Schwake C et al. Adjuvant auricular electroacupuncture and autogenic training in rheumatoid arthritis: a randomized controlled trial. Auricular acupuncture and autogenic training in rheumatoid arthritis. Forsch Komplementmed 2008; 15(4):187-93.
  26. Acupuncture. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2009 August) Surgery 7.01.01.
  27. Kalichman, L and S. Vulfsons. Dry needling in the management of musculoskeletal pain. JABFM 2010; 23(5)-640-6.
  28. Cotchett MP, Landorf KB, Munteau SE. Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: A systematic review. J Foot Ankle Res 2010; 3:18.
  29. Position Paper on Dry Needling. Council of colleges of acupuncture and oriental medicine. 2011 Available at www.ccaom.org (accessed June 26, 2012).
  30. Furlan AD. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews. 2011 (2).  
  31. Holzer A, Leitgeb U, Spacek A et al. Auricular acupuncture for postoperative pain after gynecological surgery: a randomized controlled trail. Minerva Anestesiol 2011; 77(3):298-304.
  32. Auricular Electrostimulation. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 September) Surgery 8.01.58.
History
October 2013  New 2013 BCBSMT medical policy.  Acupuncture in any form is considered experimental, investigational and unproven. 
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Acupuncture