Samuel A. Collins
Question: When an insurance plan allows 24 acupuncture visits per year, does this allow the patient to use 24 visits automatically? I have a patient insisting this is what they were told and they want to schedule two visits per month for the entire year.
This is an often-confusing statement from an insurance plan and in terms of how it is interpreted by the patient. They see they get a set number of visits and assume this allows them to use the visits at their discretion.
It is always important for our understanding and the information we provide to the patient that patients know they are allowed the 24 visits per year, but that visits must be medically necessary and for a covered condition for which acupuncture has been approved. It is not an open invitation to simply receive acupuncture services.
When the condition and diagnosis warrants, up to 24 visits are allowed. However, the 24 visits are not automatic, as the severity and patient response will dictate the necessity. It is the duty of the provider to explain this nuance, as only 4-6 visits may be necessary for a simple, acute condition compared to a severe or chronic condition, which may require all 24 visits.
A Few Insurer Examples
When you have any plan with acupuncture benefits, always verify what conditions or diagnoses are required. For example, Aetna states that acupuncture (manual or electroacupuncture) is medically necessary for any of the following:
- Chronic (minimum 12 weeks duration) neck pain
- Chronic (minimum 12 weeks duration) headache
- Low back pain
- Nausea of pregnancy
- Pain from osteoarthritis of the knee or hip (adjunctive therapy)
- Post-operative and chemotherapy-induced nausea and vomiting
- Post-operative dental pain
- Temporomandibular disorders (TMD)
Cigna indicates that acupuncture can be provided 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)
- Nausea associated with chemotherapy (only when co-managed)
These examples demonstrate a clearly defined requirement to access acupuncture benefits. The patient may have an annual visit count of 24 or even unlimited, but necessity is still required.
Medical Necessity
Medical necessity, as defined by most carriers, will adhere to the following points:
- 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 toward 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.
It is also important to understand what carriers generally define as not medically necessary. Maintenance treatment, performed when the member’s symptoms are neither regressing nor improving, is considered not medically necessary. If no clinical benefit is appreciated after four weeks of acupuncture, then the treatment plan should be re-evaluated. Further, acupuncture treatment is not considered medically necessary if the patient does not demonstrate meaningful improvement in symptoms.
With proper planning and evidence, there may be room for supportive care, also referred to as ongoing care or long-term treatment or care. Supportive care may be necessary as a treatment for individuals who have reached a maximum benefit, but fail to sustain the benefit and progressively deteriorate when removed from treatment programs.
The potential for the individual to develop a dependency on ongoing care should be considered in treatment planning. Once a maximum benefit has been reached, continuing acupuncture care is considered not medically necessary.
I recommend the use of validated outcome tools such as the Oswestry Disability Questionnaire, the General Pain Disability Index Questionnaire or the Pain Interference Short Form, as they are easy-to-use tools that will demonstrate the ongoing progress of the patient with insurance carriers. This has a great deal of value when insurers review a claim for necessity.
A provider’s goal is always to afford the best quality and care for their patients and achieve optimal access to the benefits patients may have. While it is an extremely positive trend for more plans to cover acupuncture and the potential for a significant amount of visits, it is important to keep in mind what the requirements are for this coverage. There will be a need to have a conversation with the patient so there is a clear understanding, rather than unrealistic expectations.
Editor’s Note: Have a billing question? Submit it to Sam via email at sam@hjrossnetwork.com. Submission is acknowledgment that your question may be the subject of a future column.
