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Product Overview D-SNP
Acupuncture for chronic low back pain (cLBP)
Last Updated on November 08, 2022
Effective for claims with DOS on or after January 21, 2020, Security Health Plan Medicare Advantage plans will cover acupuncture for chronic low back pain reported with CPT codes 97810, 97811, 97813, 97814, 20560, and 20561 as covered services under NCD 30.3.3. If a member does not meet the coverage criteria outlined in NCD 30.3.3 then affiliated providers must submit an organization determination to deny non-covered services to the member. Non-affiliated providers may have the member sign an Advanced Beneficiary Notice (ABN) and bill with appropriate modifier on the claim for services to deny to the member.
Covered services include up to 12 acupuncture visits in 90 days for Medicare beneficiaries with a diagnosis of chronic low back pain. An additional 8 sessions may be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is regressing. For the purpose of this benefit, chronic low back pain is defined as:
- Lasting 12 weeks or longer;
- Nonspecific, in that it has no identifiable systemic cause (i.e. not associated with metastatic disease, inflammatory disease, infectious disease, etc.);
- Not associated with surgery;
- Not associated with pregnancy.
In addition to member coverage requirements, in order for acupuncture to be covered the following provider requirements must be met:
- Physicians (as defined in 1861(r) (1) of the Social Security Act (the Act) may furnish acupuncture in accordance with applicable state requirements.
- Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs) (as identified in 1861(aa) (5) of the Act), 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)
- 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 furnishing acupuncture must be under the appropriate level of supervision of a physician, PA, or NP/CNS required by our regulations at 42 CFR §§ 410.26 and 410.27.
There could be cost share associated with this benefit. To view a member’s eligibility and benefits log in to the Security Health Plan Provider Portal. For plan specific documents such as the EOC, see https://www.securityhealth.org/brokers/document-library/medicare-documents.