Acupuncture now covered for Medicare members with chronic low back pain

In response to guidance from the Centers for Medicare and Medicaid Services (CMS), we're now covering acupuncture for Medicare Advantage members with chronic low back pain (cLBP), for claims with dates of service on or after Jan. 21, 2020.

This change impacts members with any type of Priority Health Medicare Advantage plan, including individual MAPD plans, Medicare Employer Group Waiver Plans (EGWPs) and PriorityMedicare D-SNP. Becasue this is a mid-year change, the benefit is not reflected in Medicare member Evidences of Coverage (EOCs).

Acupuncture benefit information

Acupuncture is defined as the "selection and manipulation of specific acupuncture points through the insertion of needs or 'needling,' or other 'non-needling' techniques focused on these points".

After its most recent national coverage analysis for acupuncture specifically targeted for cLPB, CMS determined it will cover acupuncture for claims with dates of service on or after Jan. 21, 2020. Up to 12 visits in 90 days are covered for Medicare beneficiaries. For this decision, cLBP is defined as:

  • Lasting 12 weeks or longer;
  • Non-specific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
  • Not associated with surgery; and,
  • Not associated with pregnancy. 

An additional eight sessions will be covered for those patients demonstrating an improvement. For these visits (visits 13 - 20), the provider must bill the KX modifier, indicating the patient is improving and the visits are medically necessary. No more than 20 acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or regressing.

Example: If the first service is performed on Mar. 21, 2020, the next service beginning a new year cannot be performed until Mar. 1, 2021. This means 11 full months must pass from the date of the 1st service before eligibility begins again.

All types of acupuncture, including dry needling for any condition other than cLBP are non-covered by Medicare.

Who can provide acupuncture services to Priority Health Medicare members?

Per CMS guidelines:

  • Physicians may furnish acupuncture in accordance with applicable state requirements.
  • Physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:
    • A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
    • Current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by CMS regulations at 42 CFR §§ 410.26 and 410.27.

Billing and coding for acupuncture services

Billing and coding guidelines for acupuncture services are available in our Provider Manual, under Procedures & Services.