|Highmark Commercial Medical Policy - Pennsylvania|
|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:
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.
|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|
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.
07/2015, Facility Applied to Acupuncture