Medicare Coverage for Acupuncture: What You Need to Know
On January 21, 2020, the Centers for Medicare & Medicaid (CMS) issued a final decision stating that Medicare will now cover acupuncture for patients with chronic low back pain (cLBP).
According to CMS: “The decision regarding coverage takes into account an assessment of benefits and harms and the opioid public health crisis. While a small number of adults 65 years of age or older have been enrolled in published acupuncture studies, patients with chronic low back pain in these studies showed improvements in function and pain. The evidence reviewed for this decision supports clinical strategies that include nonpharmacologic therapies for chronic low back pain. CMS notes too that while there is variation in covered indications and frequency of services, a number of large private payers provide some coverage of acupuncture for certain indications.”
Prior to finalizing its decision, CMS opened a National Coverage Analysis (NCA) for initial 30-day public comment on January 15, 2019, and another 30-day public comment period for the proposed decision memorandum posted on July 15, 2019. There were 755 and 644 comments received, respectively, for each period.
So far, here’s what is known about this expanded Medicare coverage.
What types of Low Back Pain are covered?
Medicare will cover acupuncture for chronic low back pain that meets the following criteria:
Lasting 12 weeks or longer;
Nonspecific, 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.
How many acupuncture sessions will be covered, and for how long?
Up to 12 visits in 90 days will be covered. If the patient shows improvement, an additional eight sessions may be covered.
However, no more than 20 acupuncture treatments may be administered per year. In addition, “[t]reatment must be discontinued if the patient is not improving or is regressing.”
Will Medicare cover acupuncture for conditions other than chronic low back pain?
At this time, the decision states that “[a]ll types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.”
Will Medicare cover dry needling?
To reiterate, “[a]ll types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.”
Does Medicare have any specific requirements for acupuncturists administering the chronic low back pain treatment to be covered?
Under the new Medicare coverage, physicians (as defined in 1861(r)(1)) can administer acupuncture “in accordance with applicable state requirements.”
If a non-physician (i.e. physician assistants, nurse practitioners/clinical nurse specialists (as identified in 1861(aa)(5)), and “auxiliary personnel”) will administer acupuncture, he or she must:
Meet all applicable state requirements;
Hold 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
Have a 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 must be “under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by our regulations at 42 CFR §§ 410.26 and 410.27.”
In addition, the decision states:
“Currently, acupuncturists are not recognized by CMS as Medicare providers, and are not eligible to bill for acupuncture services. It is possible, however, for acupuncturists to provide acupuncture as auxiliary personnel ‘incident to’ a physician’s service in certain settings. The incident to regulations requires supervision by a physician or other practitioner. For further details regarding ‘incident to’ services, we recommend that interested parties consult 42 CFR §§410.26 and 410.27. We are not able to amend these regulations through the national coverage determination process, however, we will change the specific reference to ‘direct supervision’ and will substitute the appropriate level of supervision required by our regulations at 42 CFR §§ 410.26 and 410.27.”
To date, CMS has yet to clarify what it means by “appropriate level of supervision” by the above mentioned personnel.
Can Licensed Acupuncturists (non-M.D.) bill Medicare for chronic low back pain treatments?
At this time, Licensed Acupuncturists cannot bill Medicare for treatment of chronic low back pain because Medicare does not allow Licensed Acupuncturist to be Medicare providers.
Where can I find more information about Medicare coverage for acupuncture for chronic low back pain?
The American Society of Acupuncturists (ASA) is in the process of addressing/clarifying the potential issues that may arise from the current CMS decision.
The full decision memo may also be accessed here.