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.
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.
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 Treatment was performed once weekly for 6 weeks, with needles withdrawn 48 hours after insertion.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)
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.
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.
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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.
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