Insurance Insight

For the Acupuncture Insurance Coverage In Utah, Some Blue Cross health plans cover acupuncture when it is medically necessary and prescribed by your doctor. Your doctor may prescribe acupuncture to treat:

• Chronic pain that has lasted at least six months and did not respond to more conservative forms of treatment, like drugs or physical therapy
• Nausea due to surgery or chemotherapy

Standard Aetna plans to extend the coverage of Acupuncture Insurance Coverage In Utah for medically necessary indications when administered by a health care provider practicing within the scope of his/her license.

Some Aetna plans limit coverage of Acupuncture Insurance Coverage In Utah to when it is used in a lieu of other anesthesia for a surgical or dental procedure covered under the health benefits plan, and the health care provider administering it is a legally qualified physician practicing within the scope of his/her license.

Some other plans may extend acupuncture insurance coverage in Utah for medically necessary indications, but only when administered by a health care provider who is a legally qualified physician practicing within the scope of his/her license.  Please check benefit plan descriptions for details.

Aetna considers needle acupuncture (manual or electroacupuncture) medically necessary for any of the following indications:

• Chronic (minimum 12 weeks duration) neck pain; or
• Chronic (minimum 12 weeks duration) headache; or
• Low back pain; or
• Nausea of pregnancy; or
• Pain from osteoarthritis of the knee or hip (adjunctive therapy); or
• Post-operative and chemotherapy-induced nausea and vomiting; or
• Post-operative dental pain; or
• Temporomandibular disorders (TMD).

Maintenance treatment, where the member’s symptoms are neither regressing or improving, is considered not medically necessary.

If no clinical benefit is appreciated after four weeks of acupuncture, then the treatment plan should be reevaluated. Further acupuncture treatment is not considered medically necessary if the member does not demonstrate meaningful improvement in symptoms.

Aetna considers acupuncture experimental and investigational for all other indications, including but not limited to any of the following conditions, because there is inadequate scientific research assessing the efficacy of acupuncture compared with placebo, sham acupuncture, or other modalities of treatment in these conditions: [Read more]

Aetna considers acupuncture point injection (also known as acupoint injection therapy, biopuncture) experimental and investigational for the following conditions (not an all-inclusive list) because the effectiveness of this approach has not been established:

• Amyotrophic lateral sclerosis.
• Cancer-related pain
• Cervical spondylosis
• Chronic daily headache
• Dysmenorrhea (menstrual pain)
• Lateral elbow pain (tennis elbow).

Aetna considers dry needling experimental and investigational because of inadequate evidence of its effectiveness.

We address the use of acupuncture to our Acupuncture Insurance Coverage In Utah which is the practice of stimulating specific points on the body using needles for the purpose of treating various health conditions. Manual manipulation or electrical stimulation of the needles may or may not be incorporated into therapy.

Note: For additional information regarding the use of auricular electroacupuncture, please see:

• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

Medically Necessary:

The use of acupuncture is considered medically necessary for the treatment of nausea and vomiting associated with surgery, chemotherapy, or pregnancy.

The use of acupuncture is considered medically necessary for treatment of painful chronic osteoarthritis of the knee or of the hip that is significantly affecting daily activity.

Not Medically Necessary:

Acupuncture is considered not medically necessary when the criteria above are not met, and for any other indication.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met, for the following procedure code, or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Acupuncture insurance coverage in Utah is subject to the terms, conditions, and limitations of the benefits as described in the applicable plan’s schedule of copayments. Please refer to the applicable benefit plan document to determine benefit availability and the terms and conditions of coverage

Medically Necessary

If coverage for acupuncture services are available in the applicable benefit plan document, Acupuncture Insurance Coverage In Utah may be provided as treatment for ANY of the following conditions when ALL of the medical necessity factors and ALL of the treatment planning /outcomes listed below are met:

• Tension-type Headache; Migraine Headache with or without Aura
• Musculoskeletal joint and soft tissue pain (e.g., hip, knee, spine) resulting in a functional deficit (e.g., inability to perform household chores, interference with job functions, loss of range of motion)
• Nausea Associated with Pregnancy (only when co-managed)
• Post-Surgical Nausea (only when co-managed) Acupuncture (CPG 024)
• Nausea Associated with Chemotherapy; (only when co-managed)

Medical Necessity Factors:

• Medically necessary services must be delivered toward defined reasonable and evidence-based goals;
• Medical necessity decisions must be based on patient presentation including diagnosis, severity, and documented clinical findings;
• Continuation of treatment is contingent upon progression towards defined treatment goals and evidenced by specific significant objective functional improvements (e.g., outcome assessment scales, range of motion)
• Certain conditions require that the patient is being co-managed by a medical physician in order to be considered medically necessary;
• Medically necessary services include monitoring of outcomes and progress with a change in treatment or withdrawal of treatment if the patient is not improving or is regressing.

Treatment Planning/Outcome Factors:

• An individualized treatment plan (e.g., frequency and duration of service) is appropriately correlated with clinical findings and clinical evidence;
• Treatment is expected to result in significant therapeutic improvement over a clearly defined period of time;
• Therapeutic goals are functionally oriented, realistic, measurable, and evidence-based;
• The proposed date of release/discharge from treatment is estimated;
• Functional Outcome Measures (FOM), when used, demonstrates Minimal Clinically Important Difference (MCID) from baseline results through periodic re-assessments;
• Documentation substantiates practitioner’s diagnosis and treatment plan;
• Demonstration of progression toward active home/self-care and discharge, and;
• Maximum therapeutic benefit has not been reached

• There are some alternative treatments that your health plan may cover. Acupuncture and chiropractic care may be covered if they’re medically necessary. Many plans include physical therapy, and if massage therapy is determined a part of your therapy, it could be covered, too.
• The best way to find out what’s covered in Acupuncture Insurance Coverage In Utah Policy is to take a look at your plan details. Sign in at regence.com, and select My benefits. Your Medical Benefits Booklet outlines what kind of treatments are covered under your plan.If you have further questions—like if you’ll need a prescription, or if you’re limited to a number of visits—reach out to Customer Service.

All claims must include both the International Classification of Diseases, Ninth Revision (ICD-9), and Current Procedural Terminology (CPT® ) codes to ensure accurate processing. The diagnosis must match the diagnosis of the referring physician.

When billing for acupuncture services, please use:

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis, or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

8 Minute Rule for Timed Codes – One Service

For services billed in 15-minute units, count the minutes of skilled treatment provided.

Only direct, face-to-face time with the patient is considered for timed codes.

• 7 minutes or less of a single service is not billable.
• 8 minutes or more of a single service is billable as 1 unit or an additional unit if the prior units were each furnished for a full one.

15 minutes:

• 8 – 22 minutes = 1 unit
• 23 – 37 minutes = 2 units
• 38 – 52 minutes = 3 units

Note: Evaluation and management (E&M) codes cannot be used as a substitute for acupuncture treatments.

Acupuncture for the treatment of chemical dependency

A participating acupuncturist/east Asian medicine practitioner will be reimbursed for acupuncture services provided for chemical dependency treatment when the member’s plan includes a benefit for both acupuncture services and chemical dependency treatment.

Acupuncture treatment for chemical dependency is covered in the following instances:

• When the member’s plan covers acupuncture
• Diagnosis supports chemical dependency benefits
• When smoking cessation is covered under some plans
• If required by the member’s plan, a referral by the member’s primary care physician or by the contracted behavioral health department organization has been filed with Regence