Mutual of Omaha
Health Care Management Operations

Medical Necessity Criteria


Effective Date: 12/02/1997

Revision Date: 11/21/2006, 12/19/2005, 11/30/2004, 11/17/2003, 11/11/2002, 07/17/2000, 04/19/99, 03/03/98,

97810-97811 without electrical stimulation / ambulatory
97813-97814 with electrical stimulation / ambulatory

Assistant Surgeon:

Cross References:
**NOTE** Medical Specialty opinions regarding the appropriateness and efficacy of acupuncture vary. Some State Insurance Laws mandate allowance of coverage of acupuncture by a provider licensed in acupuncture. Acupuncture is generally not covered by our group policies. If the policy language and /or Rider does provide coverage for acupuncture services, these should be provided by a licensed acupuncturist and follow the benefit limitations of the policy and the guidelines noted below.
Definition: Acupuncture is the Chinese practice of piercing specific nerve areas with needles for pain relief or for induction of surgical anesthesia. Treatment should be provided only by a provider licensed or certified in acupuncture.

Failure of documented traditional conservative medical management with the use of NSAIDS/Steroids, Physical Therapy, Topical Agents, or Medical Pain Management for a minimal period of 3 months AND
Treatment is Indicated for one of the following conditions:
1) Rheumatoid Arthritis/Osteoarthritis
2) Neuritis
3) Intractable pain
4) Bursitis
5) Neuralgia
6) Low Back Pain/Strain
7) Migraines
8) Chronic Headaches/Tension Headaches

Treatment for any other conditions should be referred for physician review and determination of medical necessity.

Initial certification should be for no more than 3 visits. Benefit from acupuncture is expected to become apparent after 2 or 3 treatments. Additional treatments may be indicated if there has been documented progressive, more pronounced, and more prolonged benefit with each subsequent treatment. Limitations should follow policy benefits provided as per plan language. If there has been no improvement or documented benefit from the initial 3 treatments and additional therapy is requested, physician review is then needed for certification determination.

____________________________________ ______________
Approved By: Date:
John Rule, M.D.
Corporate Medical Director
Medical Management Division

1. Federal Register. Acupuncture. National Institutes of Health Consensus Development Statement.15(5), February 4,1998, 1-25.
2. BCBS of Massachusetts. Medical Policy. Complementary Medicine: Mind-Body Medicine, Alternative Medicine, Holistic Medicine, and Other Therapies, February, 1998, 1-11.
3. Hayes, Inc; Acupuncture & Acupressure for the Treatment of Nausea and Vomiting, 4/14/98, 1- 22.
4. Hayes, Inc; Acupuncture for Addictive Behavior, 4/2/98, 1-23.
5. Hayes, Inc; Acupuncture for Treatment of Pain, 11/28/97, 1-19.
6. HCFA Coverage Issues Manual, December 2, 1999; 35-8 Acupuncture coverage.
7. Berman, B.M., Singh B.B., et al. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology. 1999, 38, 346-354.
8. Beal, MW. CNM, PhD. Acupuncture and Acupressure. Applications to Women's Reproductive Health Care. Journal of Nurse-Midwifery. May/June 1999, 44(3), 217-230.
Bibliography August 2000
9. Acupuncture. National Institute of Health Consensus Statement Online, 1997, Nov 3-5; 7/24/2000; 15(5): 1-34.
10. Ezzo J, et al. Is acupuncture effective for the treatment of chronic pain? A systematic review. PAIN. June 2000, 86(3), 217-25.
11. Mayer D.J. Acupuncture: An Evidence-Based Review of the Clinical Literature. Annual Reviews Medicine. 2000, 51, 49-63.
12. Meleger, A., Borg-Stein J. Acupuncture and Sports Medicine. A review of published studies. Medical Acupuncture. Fall 1999/Winter 2000. 11(2). Accessed 8/1/2000. Website:
13. Rotchford JK. Overview: Adverse Events of Acupuncture. Medical Acupuncture. Fall 1999/Winter 2000. 11(2). Accessed 8/1/2000. Website:
14. National Council for Reliable Health Information. NCAHF Position Paper on Acupuncture. September 16, 1990. Accessed 8/1/2000. Website:
Bibliography November 2002
15. Hayes Technology Assessment. Acupuncture and Nausea for the Treatment of Nausea and vomiting, Executive Briefings. November 1, 2001.
16. Hayes Technology Assessment. Acupuncture for the Treatment of Pain. Executive Briefings. August 25, 2001.
17. National Institute of Health (NIH). Acupuncture Shows Promise for Treating Cocaine Addiction. Internet website accessed 11/16/02. Website:
18. National Institute of Health (NIH). Education, Acupuncture Help Smokers Kick the Habit, October 15, 2002. Internet accessed 11/5/02.
Bibliography November 2003
19. Aetna Clinical Policy Bulletin. Acupuncture.
Last review update September 8, 2003.
Bibliography Update 2004
20. Aetna Clinical Policy Bulletin. Acupuncture. Last update June 8, 2004, 1-10.
21. CMS. CMS will not cover acupuncture for osteoarthritis and fibromyalgia. October 15, 2003.
22. Hayes Technology Assessment. Acupuncture and Nausea for the Treatment of Nausea and vomiting, Executive Briefings. November 1, 2001.
23. Hayes Alert Clincal Studies. Acupuncture for chronic headache, April 2004.
Bibliography Update 2005-06
1. Aetna. Clinical Policy Bulletins. Acupuncture. March 29, 2005. Accessed 6/27/2005, 11/2006:
2. American Family Physician. Trigger Points: Diagnosis and Management. February 15, 2002. Accessed 6/28/2005:
3. Blossfeldt, P. Acupuncture for Chronic Neck Pain—A Cohort Study in an NHS Pain Clinic. PubMed. Accessed 6/27/2005:
4. CIGNA. Medicare Part B Carrier-Idaho. Local Medical Review Policy. Injections of Tendon Sheaths, Ligaments, Trigger Points, or Ganglion Cysts. November 1, 1999. Accessed 6/28/2005, 11/2006:
5. CMS Manuel System. Pub. 100-03 Medicare National Coverage. Acupuncture. April 16, 2004. Accessed 6/27/2005, 11/2006:
6. CMS. Coverage Issues Manuel Medical Procedures. Acupuncture. Accessed 6/27/2005,11/2006:
7. ECRI. Custom Hotline Response. Dry Needling for Pain Management. November 30, 2004. Accessed 6/24/2005, 11/2006:
8. FDA. June 1996 FDA Consumer. Updates. Acupuncture Needles No Longer Investigational. Accessed 6/28/2005:
9. HAYES, Inc. Acupuncture and Acupressure for the Treatment of Nausea and Vomiting. February 6, 2002 (pp. 1-31).
10. HAYES, Inc. Acupuncture for the Treatment of Pain. January 20, 2005 (pp.1-35).
11. HAYES, Inc. Alert. CMS Will Not Cover Acupuncture for Osteoarthritis or Fibromyalgia. October 10, 2003. Accessed 6/24/2005, 11/2006:
12. Kerr, PD, Walsh DM, and Baxter GD. A Study of the Use of Acupuncture in Physiotherapy. PubMed. Accessed 6/27/2005:
13. National Institutes of Health. Consensus Development Conference Statement. Acupuncture. November 1997. Accessed 6/27/2005, 11/2006:
14. NCCAM. National Center for Complementary and Alternative Medicine. December 2004. Accessed 6/27/2005:
15. White, P, et al. Acupuncture versus Placebo for the Treatment of Chronic Mechanical Neck Pain: A Randomized, Controlled Trial. PubMed. Accessed 6/27/2005:

Date Archive: 01/02/2008