Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: Z-14-015
Topic: Acupuncture
Section: Miscellaneous
Effective Date: October 1, 2017
Issue Date: June 25, 2018
Last Reviewed: June 2018

Acupuncture is a therapeutic and preventive medical procedure performed by the insertion of one or more specially manufactured solid metallic needles into specific locations on the body. The intent is to stimulate acupuncture points (thereby rebalancing the body's energy flow), with or without subsequent manual manipulation.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Acupuncture is medically necessary for treating nausea associated with surgery, chemotherapy or pregnancy.

Acupuncture is medically necessary as an adjunct to standard conservative therapy for the following chronic conditions when other conservative methods of treatment have failed:

  • Chronic low back pain - back pain of at least three(3) months duration that has not responded to conservative treatment which includes physical therapy and/or pharmacotherapies such as non-steroidal anti-inflammatory drugs, muscle relaxants, and analgesics.
  • Chronic headache or migraine headache-headache experienced for 15 days or more per month, and lasting four hours a day or longer that failed first-line pharmacologic preventive therapy such as tricyclic antidepressants, beta blockers, calcium channel blockers, or valproic acid. Acupuncture is a non-pharmacological treatment option for patients with one or more of the following characteristics:
    • Poor tolerance for specific pharmacological treatments; or
    • Medical contraindications for specific pharmacological treatments; or
    • Insufficient or no response to pharmacological treatment; or
    • Pregnancy, planned pregnancy or nursing; or
    • History of long-term frequent or excessive use of analgesic or acute medications that can aggravate headache problems (or lead to decreased responsiveness to other pharmacotherapies.

Maintenance treatment where the patient’s symptoms are neither regressing nor improving is considered not medically necessary. Maintenance begins when the therapeutic goals of acupuncture have been achieved, or when no additional functional progress is apparent or expected to occur.

Acupuncture for any other indication or condition, including but not limited to acupuncture for the treatment of pain, is considered experimental/investigational, and therefore not covered. There is inadequate evidence in peer-reviewed medical literature to support the efficacy of acupuncture for the treatment of pain. 

Procedure Codes
97810, 97811, 97813, 97814

Place of Service: Outpatient

Acupuncture is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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