Insurance Carrier Increases Diagnoses Codes For Acupuncture Benefits
By Samuel A. Collins
Recently, acupuncturists have been asking me about the increase in the types of diagnoses allowed for benefits of acupuncture services from Anthem Blue Cross.
What many have heard is correct, and there has been a very large increase in the diagnoses codes allowed for acupuncture benefits. Traditionally acupuncture benefits have been limited to "pain," which does limit the number of diagnoses allowances. However, one of the genius tenets of acupuncture, in my opinion, is that there is a focus on pain. At the most basic element of the human condition the body always communicates through one profound but simple manner—pain. Acupuncturists for centuries have recognized this; therefore, a great deal of emphasis is put towards listening and utilizing the communication.
However, with pain alone there can be a barrier or limitation to the myriad of conditions that can be effectively treated by acupuncture. For example, Blue Cross had a prior policy to cover acupuncture services for a very limited number of conditions: nausea, vomiting, and arthritis of the knee & hip only.
I find this benefit so limited that there may as well no acupuncture benefits as it offers such a narrow scope. It is also interesting that under this policy it deems acupuncture as effective in treating arthritis of the knee and hip only. Based on this am I to understand then that arthritis in other joints is some "other" form of arthritis and would not have a positive response to acupuncture? I do believe all joints though shaped differently are made up the same components; bone, cartilage, ligaments, tendons, muscles etc. Is it reasonable to believe acupuncture would work on the knee and hip, but otherwise be ineffective in other joints? This policy seems void of logic.
Fast-forward to fall 2011 and Anthem Blue Cross made a major shift in the coverage and allowance for acupuncture benefits based on the allowed diagnoses. And this is what many acupuncturists are likely referring to. The new allowance for diagnosis for acupuncture is now for all diagnoses. Yes, not limited to some, but now all. The reference is the Anthem Blue Cross acupuncture Clinical UM Guideline CG-ANC-03. The effective date of this policy change was October 12, 2011.
This is a major shift and more in line with what Blue Cross has allowed in states like Massachusetts for years. Blue Cross states in the plan coverage the following: "Acupuncture as a therapeutic intervention is widely practiced in the United States. There have been many studies of its potential usefulness. However, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebo and sham acupuncture groups.
However, promising results have emerged, for example, efficacy of acupuncture in adult post-operative and chemotherapy nausea and vomiting and in post-operative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma where acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.
This statement demonstrates the beginning of a better understanding and acceptance to the validity and positive outcomes of acupuncture for a myriad of conditions and not from the dark ages of pain only. There has been a change in Anthem Blue Cross, and they now do not have diagnosis restriction for reimbursement for acupuncture services.
To reference a few other carriers, Aetna insurance does have acupuncture benefits as well and states; "Aetna considers needle acupuncture (manual or electroacupuncture) medically necessary for any of the following indications, Postoperative and chemotherapy-induced nausea and vomiting; or Nausea of pregnancy; or Postoperative dental pain; or Temporomandibular disorders (TMD); or Migraine headache; or Pain from osteoarthritis of the knee or hip (adjunctive therapy); or Fetal breech presentation(yes, breech presentation – special note this is now also covered in the state of Oregon under their Medicaid system); or Chronic low back pain. (Maintenance treatment, where the patient's symptoms are neither regressing or improving, is considered not medically necessary.)"
In fact, Aetna lists the specific codes allowed and not allowed in the Aetna Clinical Policy Bulleting 0135, which can be viewed here.
Here's one more, Cigna Insurance. Cigna states in its Medical Coverage Policy 0024 the following: "CIGNA covers acupuncture as medically necessary for any of the following indications: nausea and vomiting associated with pregnancy, nausea and vomiting associated with chemotherapy, postoperative nausea and vomiting and postoperative dental pain. CIGNA covers acupuncture as an adjunct to standard conservative therapy for the treatment of any of the following CHRONIC painful conditions when other conservative methods of treatment have failed, there is limitation resulting in impaired activities of daily living, and there is reasonable expectation treatment will result in significant therapeutic improvement over a clearly defined period of time: migraine or tension headache, osteoarthritic knee pain, neck pain, and low back pain. CIGNA does not cover acupuncture when treatment is unlikely to result in sustained improvement or when there is no defined endpoint, including preventive, maintenance or supportive care, because it is considered not medically necessary."
Cigna also in this policy bulletin specifically highlights over 45 ICD9 codes acceptable for acupuncture reimbursement. The complete document can be viewed on this link.
As a caveat, please note that acupuncture providers in some states do not have the scope of practice to make a "Western" diagnosis; therefore, this can create a barrier in that the Western diagnosis would need to come from another source—such as a medical doctor or chiropractor.
Of course, this Western diagnosis is a necessity when it comes to billing health insurance. On a positive note the ICD11 (yes, not the ICD10 that is coming) is being currently developed and there will be a separate section for Traditional Medicine diagnosis, which can hopefully eliminate this barrier of Western diagnosis only. ICD11 will be discussed in more detail in a future column.
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