Question: Is there an insurance rule regarding the maximum number of sets of acupuncture that can be reimbursed for in a single visit? I have heard a rumor that UnitedHealthcare will not pay more than four units of manual and three units of electroacupuncture units per visit. I have also seen my recent VA Choice authorizations for acupuncture limited to two sets. Do you have any information as to why this is occurring?
There is no universal insurance rule that mandates a limit for acupuncture. As with any health care intervention for pain management, necessity is determined by efficacy and the ability to reduce pain and increase function. Acupuncture includes a diverse range of philosophies and treatment styles; practitioners may have treatment protocols that implement one set only, and others that implement four or more.
In my experience providing continuing education for the acupuncture profession for almost 20 years, I have found that the average number of sets or insertions of needles per treatment session falls between 2-3 per visit, with the number closer to two than to three. I am aware of practitioners who do as many as six per visit, but those are outliers. Considering the average fee per set, six sets would create a cost per visit of at least $300 to as much as $600, and likely be cost-prohibitive to most patients and payers.
Individual Carrier Limits
To answer your direct question, there are some limits imposed by some carriers. For instance, since 2018 the Veterans Administration (VA Choice) has limited acupuncture to one initial set and one follow-up set, whether manual or electroacupuncture. I have noted this limit on most, if not all authorizations for acupuncture.
However, I have had some practitioners indicate that their authorization did not indicate such a limit, and often perform and are reimbursed for more than two sets. Therefore, I would pay special attention to the authorizations received from the VA Choice program and whether the authorization specifically indicates a limit or not.
In 2019, UnitedHealthcare's (UHC) acupuncture reimbursement policy limited acupuncture to one initial set of manual acupuncture and up to three sets of additional manual acupuncture. For electroacupuncture, it was one initial set and up to two additional sets. This set a precedent for UHC that the maximum it would reimburse would be four units of manual acupuncture and three units of electroacupuncture.
However, this policy was just updated in May 2020 and now indicates the maximum allowed for manual or electroacupuncture is three sets. This policy change was included in the Acupuncture Commercial Reimbursement Policy CMS 1500 Policy Number 2020R 6006A. [Click here to view this policy.]
"Medically Unlikely Edits"
The policy references the CMS Medically Unlikely Edits (MUE): "In accordance with the code descriptions and/or the Centers for Medicare and Medicaid Services (CMS) guidelines and CMS Medicaid National Correct Coding Initiative (NCCI) established Medically Unlikely Edits (MUE) values, the maximum units of Acupuncture services allowed per date of service."
An MUE is defined for certain CPT codes as the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. The document that policy is referencing specifically indicates limits of one initial set and up to two additional sets, regardless of manual or electrical acupuncture.
The rationale for the limit to acupuncture is based upon code description, CPT instructions and nature of service. It is specifically not indicated as a CMS policy or related to Medicare reimbursement.
Appealing an MUE
An MUE may be appealed when a claim denial is based on these edits if there is adequate documentation of medical necessity for the reported units. I have had many providers submitting VA Choice claims request and receive additional acupuncture sets per visit allowance.
With an appeal, the provider would require information on the specific need for sets exceeding the MUE with a rationale and specific goals, hopefully under some evidenced-based guidelines.
Is Trouble on the Horizon?
Thus far, very few offices have reached out to me about limits or denials of this nature, but this likely is due to the average acupuncture visit being three or fewer sets. However, I did receive a recent inquiry about a denial by Cigna on an acupuncture claim in which the claim indicated the maximum allowed sets to be three. Consequently, I believe the MUE protocols may be followed by most, if not all major payers ... which means we may see a limit of three, with additional sets requiring an appeal.
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