Cigna Medical Coverage Policy

Effective Date ............................ 3/15/2017

Next Review Date ...................... 3/15/2018
Coverage Policy Number ................. 0024
Subject Acupuncture

Table of Contents Related Coverage Resources

Coverage Policy .................................................. 1 Autism Spectrum Disorders/Pervasive
General Background ........................................... 2 Developmental Disorders: Assessment and
Coding/Billing Information ................................... 6 Treatment
References ........................................................ 10 Botulinum Therapy
Complementary and Alternative Medicine
Electrical Stimulation Therapy and Devices
Hyperbaric Oxygen Therapy, Systemic and
Topical
Infertility Services
Minimally Invasive Intradiscal/Annular
Procedures and Trigger Point Injections
Plantar Fasciitis Treatments
Recurrent Pregnancy Loss: Diagnosis and
Treatment
Temporomandibular Joint (TMJ) Disorder
Surgery

INSTRUCTIONS FOR USE

The following Coverage Policy applies to health benefit plans administered by Cigna companies. Coverage Policies are intended to provide
guidance in interpreting certain standard Cigna benefit plans. Please note, the terms of a customer’s particular benefit plan document
[Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may
differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan
document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit
plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage
mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific
instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable
laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular
situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for
treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support
medical necessity and other coverage determinations. Proprietary information of Cigna. Copyright ©2017 Cigna

Coverage Policy
Acupuncture is specifically excluded under many benefit plans. Some plans that provide coverage for
acupuncture include a maximum allowable benefit for duration of treatment or number of visits. When
the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical
necessity criteria described below are met. In addition, maintenance care is excluded under many
benefit plans. Please refer to the applicable benefit plan document to determine benefit availability and
the terms, conditions and limitations of coverage.

If coverage is available for acupuncture, the following conditions of coverage apply.

Cigna covers acupuncture as medically necessary when ALL of the following criteria have been met:

• treatment is expected to result in significant therapeutic improvement over a clearly defined period of
time

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 • individualized treatment plan with identification of treatment goals, frequency and duration
• any of the following indications:
 nausea and vomiting associated with pregnancy
 nausea and vomiting associated with chemotherapy
 postoperative nausea and vomiting
 postoperative dental pain
 the treatment of pain associated with ANY of the following chronic conditions:
o migraine or tension headache
o osteoarthritic knee pain
o neck pain
o low back pain

Cigna does not cover acupuncture for the following services because it is excluded from many benefit
plans and considered not medically necessary when used for these purposes:

• treatment intended to improve or maintain general physical condition

• maintenance acupuncture services, when significant therapeutic improvement is not expected

Cigna does not cover EITHER of the following, because each is considered experimental, investigational
or unproven:

• acupuncture point injection for any indication

• acupuncture for any other indication, including infertility and recurrent pregnancy loss

General Background
Acupuncture is a form of complementary and alternative medicine that has been widely practiced for many
centuries. It involves the stimulation of specific anatomical locations on the skin through the penetration of fine
needles, with the goal of relieving pain or treating disease. Stimulation can be accomplished manually (i.e., by a
twisting motion of the hand) or through such methods as electrical stimulation (i.e., electroacupuncture).

Acupuncture has been proposed as a treatment for acute and chronic pain conditions, including surgical
analgesia, postoperative, musculoskeletal, neurological, vascular, and craniomandibular pain as well as the pain
of malignancy. It has also been investigated as a treatment modality for a wide variety of other conditions, such
as asthma, addictive behavior, nausea, vomiting, infertility, allergic rhinitis, depression, and bowel dysfunction,
and as a weight-reduction method.

The clinical utility of acupuncture is widely debated. Evaluating the clinical efficacy of acupuncture in the context
of clinical trials is challenging primarily because of the difficulty of designing randomized trials with appropriate
blinding of both subjects and providers. Many studies lack appropriate controls, adequate study size,
randomization and/or consistent outcome measures.

Study controls for comparing real acupuncture (also referred to as verum acupuncture) typically include a
placebo, sham acupuncture, standard treatment, or no treatment. Sham acupuncture is the most often used
control in studies evaluating the efficacy of acupuncture. However, there is no standardized method for
employing sham acupuncture and no consensus on needle placement, making it difficult to generalize findings
across studies. The goal of applying sham acupuncture is to refrain from stimulating acupuncture points. In
many studies, sham is done at irrelevant acupuncture sites; however, evidence has shown sham acupuncture
evokes physiological responses. Because the evidence suggests that sham acupuncture is not truly a
physiologically neutral event, its use as a control in clinical trials is debatable. It is difficult to distinguish between
the specific effects of treatment versus that of the placebo. It has been reported that the ratio of improvement in
sham groups was substantially higher than in truly inert placebo groups (Madsen, et al., 2009; Ezzo, et al.,
2000). Although initially believed to have no effect, some researchers contend that needle placement in any
position invokes a biological response that may interfere with the interpretation of findings.

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A majority of states provide licensure or registration for acupuncture practitioners, although the scope of practice
allowed under state requirements varies. The National Institutes of Health (NIH) Consensus Panel and the U.S.
Food and Drug Administration (FDA) consider acupuncture safe when performed by qualified practitioners using
sterile needles. The FDA requires that sterile, nontoxic needles be used and that they be labeled for single use
by qualified practitioners. Acupuncture appears to be a relatively safe treatment with rare serious adverse side
effects when performed by qualified practitioners who consistently adhere to the recommendations of the FDA
regarding the use of sterile needles.

In addition to adults, acupuncture is being performed to treat a variety of conditions in children. Treatment of
children is more complex compared to adults, mainly due to physiological differences and fear of needles. As a
result, instead of inserting needles a technique such as applied pressure, electricity or laser may be used
(Libonate, et al., 2008) and is better tolerated. The amount of evidence to support safety and efficacy for use in
children is limited and primarily focuses on post-operative nausea and vomiting and acute and chronic pain.
Similar to adults, much of the data is limited by small sample size, lack of randomization, and mixed clinical
outcomes. When used to treat postoperative and chemotherapy induced nausea and vomiting there is sufficient
evidence to support safety and efficacy of acupuncture in children (Jindal, et al., 2008; Libonate, et al.,
2008).There is limited data supporting efficacy for acupuncture when used to treat headaches in adolescents
(Gottschling, et al., 2008; Kemper, et al., 2008 [Task Force on Complementary and Alternative Medicine and the
Provisional Section on Complementary, Holistic, and Integrative Medicine, American Academy of Pediatrics];
Kundu, et al., 2007) and clinical outcomes are mixed (Jindal, et al, 2008). Additional applications may include
nausea, pain and allergy (Kemper, et al., 2008), however further data from large well-designed clinical studies
are needed to support safety and efficacy for these and a variety of other pediatric conditions such as asthma,
allergic rhinitis, neurological disorders, gastrointestinal disorders, cancer pain, and addictions (Jindal, et al.,
2008).

The published, peer-reviewed scientific literature provides sufficiently strong evidence to indicate that
acupuncture is safe and effective in adults for the treatment of postoperative nausea and vomiting, nausea and
vomiting associated with pregnancy or chemotherapy, and postoperative dental pain (Smith, et al., 2002; Smith
and Crowther, 2002; Knight, et al., 2001; Lao, et al., 1999; Dundee, et al., 1989; National Institute of Health,
[NIH], 1997; Lao, et al., 1995). Treatment duration for these conditions is generally short-term as a result of the
condition being treated. There is also sufficient data in the peer-reviewed, published scientific literature
supporting safety and efficacy for the use of acupuncture as an adjunctive treatment modality for chronic pain
conditions including headaches (i.e., migraine, tension), low back pain, neck pain, and osteoarthritic knee pain.
Depending on the pain condition being treated, a course of acupuncture may last several weeks. Although there
is no consensus in the scientific literature regarding the optimal number of acupuncture treatments to administer
or the duration of treatment for any condition, in general, there should be a reasonable expectation for clinical
improvement. If no improvement is documented after an initial trial of two-four weeks treatment, an alternative
treatment plan should be considered. If lack of clinical improvement continues following subsequent treatments
re-evaluation by the referring provider may be indicated. If measurable objective improvement is made, then
progress towards identified goals should be clearly documented and the treatment plan updated accordingly.
The necessity of continued care beyond a therapeutic trial is dependent upon objective evidence of
improvement (i.e., functional gain).

Headaches
Evidence in the medical literature evaluating the safety and effectiveness of acupuncture as a treatment for
chronic headaches consists largely of randomized controlled trials, case reports/series, and systematic reviews.
Although the clinical trials have limitations and do not lead to strong, definitive conclusions, they are suggestive
of improved clinical outcomes for chronic migraine and tension headaches (Wang, et al., 2012; Sun and Gan,
2008; Endres, et al., 2007; Alecrim-Adrade, et. al., 2007; Diener, et al., 2006; Coeytaux, et al., 2005; Vickers, et
al., 2004; Malchert, et al., 2003; Allais, et al., 2003; Malchert, et al., 2001). The number of treatment sessions
and duration of treatment within these studies vary; the total treatment sessions ranged from one to 16 while the
duration of treatment ranged from one single treatment (prevention at onset) to 24 weeks.

Pain Conditions
Acupuncture has also been investigated for the treatment of pain conditions such as chronic neck and low back
pain; although some of the evidence supporting the efficacy of acupuncture for these treatments has been
contradictory. Various studies have compared the effectiveness of acupuncture to that of sham acupuncture,
placebo, and massage therapy, as well as to the effectiveness of self-care for low back pain and neck pain.

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Neck Pain: Chronic neck pain is a common condition with multiple etiologies, and is often treated with
acupuncture. Although the evidence evaluating acupuncture as an alternative or adjunctive form of treatment for
chronic neck pain is limited, some authors report that acupuncture is beneficial in the treatment of this condition
(Blossfeldt, 2004; Irnich et al., 2001) while others claim there is a lack of evidence to support acupuncture as an
effective treatment modality (White and Ernst, 1999). Nonetheless, while more robust research may be useful,
the available evidence does suggest that acupuncture is a worthy option as an adjunct to other neck pain
treatments. In general, the average number of acupuncture treatment sessions varies as well as the duration of
treatment across clinical trials, however, the average number of treatment sessions for treating chronic neck
pain range from one to two sessions per week provided over a range of three to 12 weeks.

Published evidence evaluating acupuncture for the treatment of neck pain is primarily in the form of systematic
reviews and meta analysis (with some overlapping of studies) (Leaver, et al.,2010; Fu, et al., 2009; White and
Ernst, 2009; Trinh, et al., 2007[Cochrane], Birch, et al., 2004) randomized controlled trials (Sun, et Al., 2010;
Vas, et al., 2006; Witt, et al., 2006; White, et al., 2004; Irnich, et al., 2001), and prospective clinical trials
(Franca, et al., 2003; Zhu, et al., 2002, David, et al., 1999).

Back Pain: Evidence in the form of systematic reviews, randomized controlled trials, meta-analyses and
observational studies evaluate the use of acupuncture for treating low back pain. While the etiology of back pain
is not specified, the subjects enrolled in the majority of clinical trials were experiencing chronic low back pain.
Few authors have evaluated the efficacy of acupuncture for treatment of acute episodes of back pain (Lee, et
al., 2013; Vas, et al., 2012; Furlan, et al, 2005, Manheimer, et al., 2005). In general the published evidence is
conflicting/contradictory with some authors reporting acupuncture may be beneficial (Liu, et al., 2015; Cho, et
al., 2012; Trigkilidas, 2010; Yuan, et al., 2008; Haake , et al., 2007; Weidenhammer et al., 2007; Brinkhaus, et
al., 2006; Inoue et al., 2006; Hsieh, et al., 2006; Thomas, et al., 2005; Furlan, et al., 2004; Meng, t al., 2003;
Molsberger, et al., 2002; Leibing, et al., 2002; Carlsson, et al., 2001) while others report a benefit is unclear
(Cherkin, et al., 2003; Kerr, et al., 2003; van Tulder, et al., 1999; Ernst and White, 1998). In May 2009 the
National Institute for Health and Clinical Excellence (NICE) published guidelines for back pain which included a
course of acupuncture as a treatment option. Some authors do not define the number of treatment sessions
and/or duration of treatment although similar to other pain conditions, treatment sessions in these studies
ranged from one to five times per week, (averaging one to two treatments), over a duration of four to 12 weeks.

Osteoarthritic Knee Pain: Researchers also suggest that acupuncture is an effective complement to standard
care for chronic osteoarthritis of the knee. Some of the conclusions are limited by the poor quality of the study
design. In a majority of the studies osteoarthritis was confirmed by radiographs. Although clinical trials have
yielded inconsistent results for a variety of reasons, there is some evidence supporting the efficacy of
acupuncture as an adjunct or alternative treatment for osteoarthritis of the knee (Lin, et al., 2016; Hou, et al.,
2015; Mavrommatis, et al., 2012; Manheimer, et al., 2010; Suarez – Almazor, et al., 2010; Miller, et al., 2009;
Jubb, et al., 2008; Manheimer, et al., 2007; White, et al., 2007; Williamson, et al., 2007; Scharf, et al., 2006;
Witt, et al., 2006; Witt, et al., 2005; Berman, et al., 2004; Vas , et al., 2004; Sandee, et al., 2002; Ezzo, et al.,
2001).Treatment sessions within these studies ranged from one to two treatment sessions per week, for an
average of eight to 12 weeks.

Other Indications
The volume of literature reporting on the efficacy of acupuncture for other indications is extensive and includes
conditions such menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, carpal tunnel,
temporomandibular joint pain, and correction of breech presentation. However, the overall body of evidence for
these indications is generally of poor quality, consisting of numerous uncontrolled studies, small case series,
case reports, and anecdotal information. Sample sizes are generally inadequate to identify real differences
between treatment and control groups, data on long-term outcomes are lacking, there is no consensus
regarding patient selection criteria and well-designed, large-population, randomized, controlled clinical trials are
lacking. Several systematic reviews of the literature involving acupuncture have concluded that, while
acupuncture may be superior to various controls, there is insufficient evidence to conclude that it is better than
placebo for most indications. In addition, technology assessments conducted by the Agency for Healthcare
Quality and Research (AHRQ) concluded there is insufficient evidence to support the efficacy of acupuncture for
the treatment of fibromyalgia and osteoarthritis (AHRQ, 2003a; AHRQ, 2003b). Acupuncture has not been
proven effective in the peer-reviewed published scientific literature for the treatment of any of the following
conditions, including but not limited to:

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 • acute pain
• addictive behaviors, including chemical and tobacco addictions
• allergies
• as a weight reduction modality
• asthma
• attention-deficit/hyperactivity disorder
• autism spectrum disorders
• bowel dysfunction
• bursitis
• carpal tunnel syndrome
• correction of breech presentation
• depression
• dermatitis or psoriasis
• dysmenorrhea
• epicondylitis (tennis elbow)
• fibromyalgia
• hypertension
• in lieu of traditional anesthesia
• infertility
• labor
• myofascial pain syndrome
• neuropathies
• nocturnal enuresis
• pain of malignancy
• plantar fascitiis
• post-stroke rehabilitation
• reflex sympathetic dystrophy
• recurrent pregnancy loss
• temporomandibular joint disorders (TMJ)
• tinnitus
• urinary incontinence (all types)

Acupuncture Point Injection Therapy

Acupuncture point injection therapy is a procedure where pharmaceuticals and natural biologic products such as
vitamins, herbal extracts and other homeopathics, are injected into the body at acupuncture points to prevent or
treat disease. One solution in particular, isotonic saline, when injected theoretically allows activation of the
acupuncture point for a longer period of time enhancing the therapeutic effect. There is insufficient evidence in
the peer-reviewed published scientific literature to support safety and efficacy at this time, data comparing the
effectiveness of different products, methods of stimulation and overall clinical utility is lacking.

Professional Societies/Organizations
Professional societies and organizations have studied and commented on the safety and efficacy of
acupuncture for various diseases and conditions. Recommendations from initial reports were based on varying
levels of evidence and there was little consensus regarding what conditions acupuncture may be considered
effective for (National Institute of Health [NIH], 1997; United Kingdom National Health Service [Vickers, 2001];
Alberta Heritage Foundation for Medical Research [Tait, et al.] 2002; World Health Organization [WHO], 2003).

Consensus statements or formal recommendations regarding acupuncture are lacking in the published
literature, however some professional societies have addressed the use of acupuncture in other guidelines. The
American College of Physicians (ACP) and American Pain Society developed evidence-based clinical practice
guidelines for diagnosing and treating low back pain in the primary care setting. According to the guideline
recommendations, acupuncture is considered a moderately effective nonpharmacologic therapy for treating
chronic low back pain (Chou, et al., 2007).

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The American Academy of Orthopaedic Surgeons (AAOS) published an update to their clinical practice
guidelines for the treatment of osteoarthritis of the knee (AAOS, 2013). Within these guidelines the AAOS does
not recommend acupuncture for the treatment of osteoarthritis of the knee due to lack of evidence supporting
efficacy. The AAOS noted the review consisted of five high quality and five moderate quality studies that
compared acupuncture to subjects receiving sham, usual care, or education. The committee concluded a
majority of studies were not statistically significant, many were not clinically significant, and that some outcomes
were associated with clinical significance but not statistical significance.

Use Outside of the US: Acupuncture is performed in several countries outside the United States and the World
Health Organization (WHO, 2003) has identified more than 40 conditions for which acupuncture may be
considered effective. For example, treatment guidelines are available from the United Kingdom for the use of
acupuncture as treatment for pain and other conditions. Singapore only considers needle acupuncture as an
approved service whereas other acupuncture modalities are not supported. In addition, although high quality
evidence in the peer reviewed scientific English literature is limited, the use of acupuncture as a treatment
modality for many conditions is widely accepted in the Chinese culture where acupuncture is often considered
part of Traditional Chinese Medicine (TCM).

Summary
Despite the lack of strong scientific evidence, acupuncture is accepted as a form of complementary and
alternative medicine for selected conditions, including treatment of postoperative nausea and vomiting, nausea
and vomiting associated with pregnancy or chemotherapy, and postoperative dental pain. Treatment for these
conditions is generally of short duration. Clinical studies provide some evidence to support the effectiveness of
acupuncture for the treatment of chronic headaches, low back and neck pain and osteoarthritis of the knee.
Acupuncture may be a viable option as an adjunctive method of treatment for these conditions, when other
conventional modalities have failed, and when there is reasonable expectation treatment will result in significant
therapeutic improvement over a clearly defined period of time. While there is no consensus regarding the
number of treatment sessions or duration of treatment, published scientific evidence suggests acupuncture is
effective for pain relief, when performed one to two times weekly for 10 to 12 weeks on average. Acupuncture is
considered not medically necessary when treatment is unlikely to result in sustained clinical improvement or
when there is no defined endpoint for treatment, such as when provided for preventive, maintenance or
supportive treatment. Acupuncture as a treatment for any other condition, including acupuncture point injection
therapy, has not been proven effective in the published peer-reviewed scientific literature.

Coding/Billing Information
Note: 1) This list of codes may not be all-inclusive.
2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible
for reimbursement.

Acupuncture

Covered when medically necessary:

®
CPT * Description
Codes
97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes
of personal one-on-one contact with the patient
97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional
15 minutes of personal one-one contact with the patient, with re-insertion of
needle(s) (List separately in addition to code for primary procedure)
97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of
personal one-on-one contact with the patient
97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15
minutes of personal one-one contact with the patient, with re-insertion of
needle(s) (List separately in addition to code for primary procedure)

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 ICD-9-CM Description
Diagnosis
Codes
307.81 Tension headache
338.12 Acute post-thoracotomy pain
338.18 Other acute postoperative pain
338.28 Other chronic postoperative pain
339.10- Tension type headache
339.12
346.00- Migraine
346.93
353.2 Cervical root lesions, not elsewhere classified
353.4 Lumbosacral root lesions, not elsewhere classified
564.3 Vomiting following gastrointestinal surgery
643.00 Mild hyperemesis gravidarum, unspecified as to episode of care or not
applicable
643.03 Mild hyperemesis gravidarum, antepartum condition or complication
643.10 Hyperemesis gravidarum with metabolic disturbance, unspecified as to episode
of care or not applicable
643.13 Hyperemesis gravidarum with metabolic disturbance, antepartum condition or
complication
643.20 Late vomiting of pregnancy, unspecified as to episode of care or not applicable
643.23 Late vomiting of pregnancy, antepartum condition or complication
643.80 Other vomiting complicating pregnancy, unspecified as to episode of care or not
applicable
643.83 Other vomiting complicating pregnancy, antepartum condition or complication
643.90 Unspecified vomiting of pregnancy, unspecified as to episode of care or not
applicable
643.93 Unspecified vomiting of pregnancy, antepartum condition or complication
715.16 Osteoarthrosis, localized, primary, lower leg
715.26 Osteoarthrosis, localized, secondary, lower leg
715.36 Osteoarthrosis, localized, not specified whether primary or secondary, lower leg
715.96 Osteoarthrosis, unspecified whether generalized or localized, lower leg
721.0 Cervical spondylosis without myelopathy
721.1 Cervical spondylosis with myelopathy
721.3 Lumbosacral spondylosis without myelopathy
721.42 Lumbar spondylosis with myelopathy
722.0 Displacement of cervical intervertebral disc without myelopathy
722.10 Displacement of lumbar intervertebral disc without myelopathy
722.4 Degeneration of cervical intervertebral disc
722.52 Degeneration of lumbar or lumbosacral intervertebral disc
722.71 Intervertebral disc disorder with myelopathy, cervical region
722.73 Intervertebral disc disorder with myelopathy, lumbar region
722.93 Other and unspecified disc disorder , lumbar region
723.0 Spinal stenosis in cervical region
723.1 Cervicalgia
723.2 Cervicocranial syndrome
723.3 Cervicobrachial syndrome (diffuse)
723.8 Other syndromes affecting cervical region
723.9 Unspecified musculoskeletal disorders and symptoms referable to neck
724.02 Spinal stenosis, lumbar region without neurogenic claudication
724.2 Lumbago
724.3 Sciatica
724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified
724.5 Backache, unspecified
724.6 Disorders of sacrum

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 724.70 Unspecified disorder of coccyx
724.79 Other disorder of coccyx
724.9 Ankylosis of spine, NOS
739.1 Nonallopathic lesions, cervical region
739.3 Nonallopathic lesions, lumbar region
739.4 Nonallopathic lesions, sacral region
739.6 Nonallopathic lesions, lower extremities
787.01- Nausea and vomiting
787.03

ICD-10-CM Description
Diagnosis
Codes
G43.001-
G43.919 Migraine
G44.221-
G44.229 Chronic tension-type headache
G89.12 Acute post-thoracotomy pain
G89.18 Other acute postprocedural pain
K91.0 Vomiting following gastrointestinal surgery
M17.0-M17.9 Osteoarthritis of knee
M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial region
M47.12 Other spondylosis with myelopathy, cervical region
M47.13 Other spondylosis with myelopathy, cervicothoracic region
M47.16 Other spondylosis with myelopathy, lumbar region
M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal
M47.818 region
M47.891 Other spondylosis, occipito-atlanto-axial region
M47.892 Other spondylosis, cervical region
M47.893 Other spondylosis, cervicothoracic region
M47.896 Other spondylosis, lumbar region
M47.897 Other spondylosis, lumbosacral region
M47.898 Other spondylosis, sacral and sacrococcygeal region
M48.01 Spinal stenosis, occipito-atlanto-axial region
M48.02 Spinal stenosis, cervical region
M48.03 Spinal stenosis, cervicothoracic region
M48.06 Spinal stenosis, lumbar region
M48.07 Spinal stenosis, lumbosacral region
M50.00 Cervical disc disorder with myelopathy, unspecified cervical region
M50.01 Cervical disc disorder with myelopathy, high cervical region
M50.02 Cervical disc disorder with myelopathy, mid-cervical region (Code invalid
09/30/2016)
M50.020 Cervical disc disorder with myelopathy, mid-cervical region, unspecified level
(Code effective 10/01/2016)
Cervical disc disorder at C4-C5 level with myelopathy (Code effective
M50.021 10/01/2016)

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 Cervical disc disorder at C5-C6 level with myelopathy (Code effective
M50.022 10/01/2016)
Cervical disc disorder at C6-C7 level with myelopathy (Code effective
M50.023 10/01/2016)
M50.03 Cervical disc disorder with myelopathy, cervicothoracic region
M50.20 Other cervical disc displacement, unspecified cervical region
M50.21 Other cervical disc displacement, high cervical region
M50.22 Other cervical disc displacement, mid-cervical region (Code invalid 09/30/2016)
M50.220 Other cervical disc displacement, mid-cervical region, unspecified level (Code
effective 10/01/2016)
M50.221 Other cervical disc displacement at C4-C5 level (Code effective 10/01/2016)
M50.222 Other cervical disc displacement at C5-C6 level (Code effective 10/01/2016)
M50.223 Other cervical disc displacement at C6-C7 level (Code effective 10/01/2016)
M50.23 Other cervical disc displacement, cervicothoracic region
M50.30 Other cervical disc degeneration, unspecified cervical region
M50.31 Other cervical disc degeneration, high cervical region
M50.32 Other cervical disc degeneration, mid-cervical region (Code invalid 09/30/2016)
M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level (Code
effective 10/01/2016)
M50.321 Other cervical disc degeneration at C4-C5 level (Code effective 10/01/2016)
M50.322 Other cervical disc degeneration at C5-C6 level(Code effective 10/01/2016)
M50.323 Other cervical disc degeneration at C6-C7 level (Code effective 10/01/2016)
M50.33 Other cervical disc degeneration, cervicothoracic region
M51.06 Intervertebral disc disorders with myelopathy, lumbar region
M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
M51.26 Other intervertebral disc displacement, lumbar region
M51.27 Other intervertebral disc displacement, lumbosacral region
M51.36 Other intervertebral disc degeneration, lumbar region
M51.37 Other intervertebral disc degeneration, lumbosacral region
M51.86 Other intervertebral disc disorders, lumbar region
M51.87 Other intervertebral disc disorders, lumbosacral region
M53.0 Cervicocranial syndrome
M53.1 Cervicobrachial syndrome
M53.3. Sacrococcygeal disorders, not elsewhere classified
M54.2 Cervicalgia
M54.30- Sciatica
M54.32
M54.40- Lumbago with sciatica
M54.42
M54.5 Low back pain
M54.89 Other dorsalgia
M54.9 Dorsalgia, unspecified
M99.01 Segmental and somatic dysfunction of cervical region
M99.03 Segmental and somatic dysfunction of lumbar region
M99.04 Segmental and somatic dysfunction of sacral region
M99.11 Subluxation complex (vertebral) of cervical region
M99.13 Subluxation complex (vertebral) of lumbar region
M99.14 Subluxation complex (vertebral) of sacral region
M99.21 Subluxation stenosis of neural canal of cervical region
M99.23 Subluxation stenosis of neural canal of lumbar region
M99.24 Subluxation stenosis of neural canal of sacral region
M99.31 Osseous stenosis of neural canal of cervical region
M99.33 Osseous stenosis of neural canal of lumbar region
M99.34 Osseous stenosis of neural canal of sacral region
M99.41 Connective tissue stenosis of neural canal of cervical region

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 M99.43 Connective tissue stenosis of neural canal of lumbar region
M99.44 Connective tissue stenosis of neural canal of sacral region
M99.51 Intervertebral disc stenosis of neural canal of cervical region
M99.53 Intervertebral disc stenosis of neural canal of lumbar region
M99.54 Intervertebral disc stenosis of neural canal of sacral region
M99.61 Osseous and subluxation stenosis of intervertebral foramina of cervical region
M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region
M99.64 Osseous and subluxation stenosis of intervertebral foramina of sacral region
M99.71 Connective tissue and disc stenosis of intervertebral foramina of cervical region
M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region
M99.74 Connective tissue and disc stenosis of intervertebral foramina of sacral region
O21.0-O21.9 Mild hyperemesis gravidarum
R11.0 Nausea
R11.10 Vomiting, unspecified
R11.11 Vomiting without nausea
R11.12 Projectile vomiting
R11.2 Nausea with vomiting, unspecified

Experimental, investigational or unproven and not covered when used to report acupuncture
for any other indication (including infertility and recurrent pregnancy loss):

ICD-9-CM Description
Diagnosis
Codes
All other codes

ICD-10-CM Description
Diagnosis
Codes
All other codes

Acupuncture Point Injection

Experimental, investigational or unproven and not covered when used to report acupuncture
point injection therapy:
®
CPT * Description
Codes
20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")
20551 Injection(s); single tendon origin/insertion
20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s)
® ©
*Current Procedural Terminology (CPT ) 2016 American Medical Association: Chicago, IL.

References
1. Agency for Healthcare Research and Quality (AHRQ). Acupuncture for fibromyalgia. Technology
assessment. 2003a Jun. Archived. Accessed February 13, 2015. Available at URL address:
http://www.ahrq.gov/clinic/techix.htm#completed

2. Agency for Healthcare Research and Quality (AHRQ). Acupuncture for osteoarthritis. Technology
assessment. 2003b Jun. Archived. Accessed February 13, 2015. Available at URL address:
http://www.ahrq.gov/clinic/techix.htm#completed

Page 10 of 20
Coverage Policy Number: 0024
 3. Alecrim-Andrade J, Maciel-Júnior JA, Carnè X, Severino Vasconcelos GM, Correa-Filho HR.
Acupuncture in Migraine Prevention: A Randomized Sham Controlled Study With 6-months
Posttreatment Follow-up. Clin J Pain. 2008 Feb;24(2):98-105.

4. Allais G, DeLorenzo C, Quirico PE, Airola G, Tolardo G, Mana O, Benedetto C. Acupuncture in the
prophylactic treatment of migraine without aura: a comparison with flunarizine. Headache. 2002 Oct;
42(9):855-61.

5. Allais G, De Lorenzo C, Quirico PE, Lupi G, Airola G, Mana O, Benedetto C. Non-pharmacological

approaches to chronic headaches: transcutaneous electrical nerve stimulation, laser therapy and
acupuncture in transformed migraine treatment. Neurol Sci. 2003 May;24 Suppl2:S138-42.

6. American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the knee (non-

arthroplasty). Full Guideline. December 6, 2008. Second edition May 2013. Accessed February 3,
2017. Available at URL address: http://www.aaos.org/Research/guidelines/guide.asp

7. Berman BM. Clinical applications of acupuncture: an overview of the evidence. J Altern Complement
Med. 2001;7Suppl 1:S111-8.

8. Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AMK, Hochberg MC. Effectiveness of acupuncture
as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2004
Dec;141(2):901-10.

9. Berman BM, Singh BB, Lao L, Langenberg P, Li H, Hadhazy V, et al. A randomized trial of
acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology (Oxford). 1999
Apr;38(4):346-54.

10. Berman BM, Swyers JP, Ezzo J. The evidence for acupuncture as a treatment for rheumatologic
conditions. Rheum Dis Clin North Am. 2000 Feb;26(1):103-15, ix-x.

11. Blossfeldt P. Acupuncture for chronic neck pain—a cohort study in an NHS pain clinic. Acupunct Med.
2004 Sep;22(3):146-51.

12. Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil S, et al. Acupuncture in patients with
chronic low back pain: a randomized controlled trial. Arch Intern Med. 2006 Feb 27;166(4):450-7.

13. Cao H, Li X, Han M, Liu J. Acupoint Stimulation for Fibromyalgia: A Systematic Review of Randomized
Controlled Trials. Evid Based Complement Alternat Med. 2013;2013:362831.

14. Cardini F, Lombardo P, Regalia AL, Regaldo G, Zanini A, Negri MG, Panepuccia L, Todros T. A
randomised controlled trial of moxibustion for breech presentation. BJOG. 2005 Jun;112(6):743-7.

15. Carlsson CP, Axemo P, Bodin A, Carstensen H, Ehrenroth B, Madegard-Lind I, Navander C. Manual
acupuncture reduces hyperemesis gravidarum: a placebo-controlled, randomized, single-blind, cross-
over study. J Pain Symptom Manage. 2000 Oct;20(4):273-9.

16. Carlsson CP, Sjolund BH. Acupuncture for chronic low back pain: a randomized placebo-controlled
study with long-term follow-up. Clin J Pain. 2001 Dec;17(4):296-305.

17. Casimiro L, Brousseau L, Milne S, Robinson V, Wells G, Tugwell P. Acupuncture and

electroacupuncture for the treatment of RA. Cochrane Database Systematic Reviews. In: The
©
Cochrane Library, Issue 2. Copyright 2005 The Cochrane Collaboration.

18. Centers for Medicare & Medicaid Services (CMS). Acupuncture for fibromyalgia; acupuncture for
osteoarthritis. National coverage determination (NCD). (30.3.2). Effective 2004 Apr 16. Accessed
February 3, 2017. Available at URL address: https://www.cms.gov/medicare-coverage-
database/indexes/ncd-alphabetical-index.aspx?bc=AgAAAAAAAAAAAA%3d%3d& =ncd

Page 11 of 20
Coverage Policy Number: 0024
 19. Cherkin DC, Eisenberg D, Sherman KJ, Barlow W, Kaptchuk TJ, Street J, Deyo RA. Randomized trial
comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for
chronic low back pain. Arch Intern Med. 2001 Apr 23;161(8):1081-8.

20. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness,
safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern
Med. 2003 Jun 3;138(11):898-906.

21. Cheuk DK, Wong V, Chen WX. Acupuncture for autism spectrum disorders (ASD). Cochrane Database
Syst Rev. 2011 Sep 7;9:CD007849.

22. Cho YJ, Song YK, Cha YY, Shin BC, Shin IH, Park HJ, et al. Acupuncture for Chronic Low Back Pain:
A Multicenter, Randomized, Patient-Assessor Blind, Sham-Controlled Clinical Trial. Spine (Phila Pa
1976). 2012 Sep 28.

23. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy
Assessment Subcommittee of the American College of Physicians; American College of Physicians;
American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: A
joint clinical practice guideline from the American College of Physicians and the American Pain
Society. October 2, 2007. Accessed February 3, 2017. Available at URL address:
http://www.acponline.org/clinical_information/guidelines/

24. Coeytaux RR, Kaufman JS, Kaptchuk TJ, Chen W, Miller WC, Callahan LF, Mann JD. A randomized,
controlled trial of acupuncture for chronic daily headache. Headache. 2005 Oct;45(9):1113-23.

25. Council of Acupuncture and Oriental Medicine Associates (CAOMA), Foundation for Acupuncture
Research. Acupuncture and electroacupuncture. Evidence-based treatment guidelines. Calistoga (CA):
Council of Acupuncture and Oriental Medicine Associates (CAOMA); 2004 Dec.

26. Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. The Cochrane
©
Database of Systematic Reviews 2007. In: The Cochrane Library Issue 1. Copyright 2007 The
Cochrane Collaboration.

27. David J, Townsend S, Sathanathan S, Kriss S, Dorė CJ. The effect of acupuncture on patients with
rheumatoid arthritis: a randomized, placebo-controlled cross-over study. Rheumatology (Oxford). 1999
Sep;38(9):864-9.

28. Diener HC, Kronfeld K, Boewing G, Lungenhausen M, Maier C, Molsberger A, Tegenthoff M,

Trampisch HJ, Zenz M, Meinert R; GERAC Migraine Study Group. Efficacy of acupuncture for the
prophylaxis of migraine: a multicentre randomised controlled clinical trial. Lancet Neurol. 2006
Apr;5(4):310-6.

29. Endres HG, Böwing G, Diener HC, Lange S, Maier C, Molsberger A, Zenz M, Vickers AJ, Tegenthoff
M. Acupuncture for tension-type headache: a multicentre, sham-controlled, patient-and observer-
blinded, randomised trial. J Headache Pain. 2007 Oct;8(5):306-14.

30. Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of
reviews. Pain. 2011 Apr;152(4):755-64.

31. Ernst E, Lee MS, Choi TY. Acupuncture for depression?: A systematic review of systematic reviews.
Eval Health Prof. 2011 Dec;34(4):403-12. Epub 2010 Dec 7.

32. Ernst E, Lee MS, Choi TY. Acupuncture in obstetrics and gynecology: an overview of systematic
reviews. Am J Chin Med. 2011;39(3):423-31.

33. Ernst E, White AR. Acupuncture as a treatment for temporomandibular joint dysfunction: a systematic
review of randomized trials. Arch Otolaryngol Head Neck Surg.1999 Mar;125(3):269-72.

Page 12 of 20
Coverage Policy Number: 0024
 34. Ernst E, White AR. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Arch
Intern Med.1998 Nov 9;158(20):2235-41.

35. Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh BB. Is acupuncture effective for the treatment
of chronic pain? A systematic review. Pain. 2000 Jun;86(3):217-25.

36. Ezzo J, Hadhazy V, Birch S, Lao L, Kaplan G, Hochberg M, Berman B. Acupuncture for osteoarthritis
of the knee: A systematic review. Arthritis Rheum. 2001 Apr;44(4):819-25.

37. Ezzo JM, Richardson MA, Vickers A, Allen C, Dibble SL, Issell BF, Lao L, Pearl M, Ramirez G, Roscoe
JA, Shen J, Shivnan JC, Streitberger K, Treish I, Zhang G. Acupuncture-point stimulation for
chemotherapy-induced nausea or vomiting. Cochrane Database of Systematic Reviews 2006, Issue 2.
©
Copyright 2007The Cochrane Collaboration.

38. França DL, Senna-Fernandes V, Cortez CM, Jackson MN, Bernardo-Filho M, Guimarães MA. Tension
neck syndrome treated by acupuncture combined with physiotherapy: A comparative clinical trial (pilot
study). Complement Ther Med. 2008 Oct;16(5):268-77.

39. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture
and dry-needling for low back pain. Cochrane Database Systematic Reviews. In: The Cochrane
©
Library, 2005 Issue 2. Copyright 2007 The Cochrane Collaboration.

40. Gottschling S, Meyer S, Gribova I, Distler L, Berrang J, Gortner L, Graf N, Shamdeen MG. Laser
acupuncture in children with headache: a double-blind, randomized, bicenter, placebo-controlled trial.
Pain. 2008 Jul 15;137(2):405-12.

41. Granato A, Chiodo Grandi F, Stokelj D, Musho S, Pizzolato G. Acupuncture in tension-type headache.
Neuroepidemiology. 2010 Aug;35(2):160-2.

42. Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Cochrane Database Systematic
©
Reviews. In: The Cochrane Library, 2005 Issue 2. Copyright 2005 The Cochrane Collaboration.

43. Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W. Acupuncture for lateral
elbow pain. Cochrane Database Systematic Reviews. In: The Cochrane Library, 2005 Issue 4.
©
Copyright 2007 The Cochrane Collaboration.

44. Haake M, Müller HH, Schade-Brittinger C, Basler HD, Schäfer H, Maier C, Endres HG, Trampisch HJ,
Molsberger A. German Acupuncture Trials (GERAC) for chronic low back pain: randomized,
multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007 Sep 24;167(17):1892-8.

45. He L, Zhou D, Wu B, Li N, Zhou MK. Acupuncture for Bell's palsy. The Cochrane Database of
©
Systematic Reviews 2004, Issue 1. Copyright 2004 The Cochrane Collaboration.

46. Hinman RS, McCrory P, Pirotta M, et al. Acupuncture for chronic knee pain: a randomized clinical trial.
JAMA. 2014 Oct 1;312(13):1313-22.

47. Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells
G, Tugwell P. American College of Rheumatology 2012 recommendations for the use of
nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis
Care Res (Hoboken) 2012 Apr;64(4):465-74.

48. Hopton A, MacPherson H. Acupuncture for chronic pain: is acupuncture more than an effective
placebo? A systematic review of pooled data from meta-analyses. Pain Pract. 2010 Mar-Apr;10(2):94-
102.

49. Hou PW, Fu PK, Hsu HC, Hsieh CL. Traditional Chinese medicine in patients with osteoarthritis of the
knee. J Tradit Complement Med. 2015 Jul 2;5(4):182-96.

Page 13 of 20
Coverage Policy Number: 0024
 50. Hsieh LL, Kuo CH, Lee LH, Yen AM, Chien KL, Chen TH. Treatment of low back pain by acupressure
and physical therapy: randomised controlled trial. BMJ. 2006 Mar 25;332(7543):696-700. Epub 2006
Feb 17.

51. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW,
Côté P, Hogg-Johnson S, Cassidy JD, Haldeman S; Bone and Joint Decade 2000-2010 Task Force on
Neck Pain and Its Associated Disorders. Treatment of neck pain: noninvasive interventions: results of
the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine.
2008 Feb 15;33(4 Suppl):S123-52.

52. Hutchinson AJ, Ball S, Andrews JC, Jones GG. The effectiveness of acupuncture in treating chronic
non-specific low back pain: a systematic review of the literature. J Orthop Surg Res. 2012 Oct 30;7:36.
doi: 10.1186/1749-799X-7-36.

53. Inoue M, Kitakoji H, Ishizaki N, Tawa M, Yano T, Katsumi Y, Kawakita K. Relief of low back pain
immediately after acupuncture treatment-a randomised, placebo controlled trial. Acupunct Med. 2006
Sep;24(3):103-8.

54. Irnich D, Behrens N, Molzen H, Konig A, Gleditsch J, Krauss M, et al. Randomised trial of acupuncture
compared with conventional massage and “sham” laser acupuncture for treatment of chronic neck
pain. BMJ. 2001 Jun;322(7302):1574-8.

55. Irnich D, Behrens N, Gleditsch JM, Stor W, Schreiber MA, Schops P, et al. Immediate effects of dry
needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind,
sham-controlled crossover trial. Pain. 2002 Sep;99(1-2):83-9.

56. Jamtvedt G, Dahm KT, Christie A, Moe RH, Haavardsholm E, Holm I, Hagen KB. Physical therapy
interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther.
2008 Jan;88(1):123-36.

57. Jevsevar DS, Brown GA, Jones DL, Matzkin EG, Manner PA, Mooar P, Schousboe JT, Stovitz S,
Sanders JO, Bozic KJ, Goldberg MJ, Martin WR 3rd, Cummins DS, Donnelly P, Woznica A, Gross L;
American Academy of Orthopaedic Surgeons. The American Academy of Orthopaedic Surgeons
evidence-based guideline on: treatment of osteoarthritis of the knee, 2nd edition. J Bone Joint Surg
Am. 2013 Oct 16;95(20):1885-6.

58. Ji J, Lu Y, Liu H, Feng H, Zhang F, Wu L, Cui Y, Wu H. Acupuncture and moxibustion for inflammatory
bowel diseases: a systematic review and meta-analysis of randomized controlled trials. Evid Based
Complement Alternat Med. 2013;2013:158352.

59. Jindal V, Ge A, Mansky PJ. Safety and efficacy of acupuncture in children: a review of the evidence. J
Pediatr Hematol Oncol. 2008 Jun;30(6):431-42.

60. Jubb RW, Tukmachi ES, Jones PW, Dempsey E, Waterhouse L, Brailsford S. A blinded randomised
trial of acupuncture (manual and electroacupuncture) compared with a non-penetrating sham for the
symptoms of osteoarthritis of the knee. Acupunct Med. 2008 Jun;26(2):69-78.

61. Jung A, Shin BC, Lee MS, Sim H, Ernst E. Acupuncture for treating temporomandibular joint disorders:
a systematic review and meta-analysis of randomized, sham-controlled trials. J Dent. 2011
May;39(5):341-50.

62. Kemper KJ, Vohra S, Walls R; Task Force on Complementary and Alternative Medicine; Provisional
Section on Complementary, Holistic, and Integrative Medicine. American Academy of Pediatrics. The
use of complementary and alternative medicine in pediatrics. Pediatrics. 2008 Dec;122(6):1374-86.

63. Kerr DP, Walsh DM, Baxter D. Acupuncture in the management of chronic low back pain: a blinded
randomized controlled trial. Clin J Pain. 2003 Nov-Dec;19(6):364-70.

Page 14 of 20
Coverage Policy Number: 0024
 64. Knight B, Mudge C, Openshaw S, White A, Hart A. Effect of acupuncture on nausea of pregnancy: a
randomized, controlled trial. Obstet Gynecol. 2001 Feb;97(2):184-8.

65. Kundu A, Berman B. Acupuncture for pediatric pain and symptom management. Pediatr Clin North Am.
2007 Dec;54(6):885-9; x.

66. Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral joint osteoarthritis: a systematic review and
meta-analysis. Rheumatology (Oxford). 2006 Nov;45(11):1331-7. Epub 2006 Aug 27.

67. Lao L, Bergman S, Hamilton GR, Langenberg P, Berman B. Evaluation of acupuncture for pain control
after oral surgery: a placebo-controlled trial. Arch Otolaryngol Head Neck Surg. 1999 May;125(5):567-
72.

68. Lao L, Bergman S, Langenberg P, Wong RH, Berman B. Efficacy of Chinese acupuncture on
postoperative oral surgery pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995
Apr;79(4):423-8.

69. Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H. Acupuncture for acute low back pain: a systematic
review. Clin J Pain. 2013 Feb;29(2):172-85. doi: 10.1097/AJP.0b013e31824909f9.

70. Leibing E, Leonhardt U, Koster G, Goerlitz A, Rosenfeldt JA, Hilgers R, Ramadori G. Acupuncture
treatment of chronic low-back pain: a randomized, blinded, placebo-controlled trial with 9-month follow-
up. Pain. 2002 Mar;96(1-2):189-96.

71. Liang Z, Zhu X, Yang X, Fu W, Lu A. Assessment of a traditional acupuncture therapy for chronic neck
pain: a pilot randomised controlled study. Complement Ther Med. 2011 Jan;19 Suppl 1:S26-32.

72. Libonate J, Evans S, Tsao JC. Efficacy of acupuncture for health conditions in children: a review.
ScientificWorldJournal. 2008 Jul 13;8:670-82.

73. Lin X, Huang K, Zhu G, Huang Z, Qin A, Fan S. The Effects of Acupuncture on Chronic Knee Pain Due
to Osteoarthritis: A Meta-Analysis. J Bone Joint Surg Am. 2016 Sep 21;98(18):1578-85.

74. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for tension-type
©
headache. The Cochrane Database of Systematic Reviews 2009 Issue 1, Copyright 2009 The
Cochrane Collaboration (a).

75. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine
©
prophylaxis. The Cochrane Database of Systematic Reviews 2009 Issue 1, Copyright 2009 The
Cochrane Collaboration (b).

76. Linde K, Jobst K, Panton J. Acupuncture for chronic asthma. Cochrane Database Systematic Reviews.
©
In: The Cochrane Library, 2005 Issue 2. Copyright 2005 The Cochrane Collaboration.

77. Liu L, Skinner M, McDonough S, Mabire L, Baxter GD. Acupuncture for low back pain: an overview of
systematic reviews. Evid Based Complement Alternat Med. 2015;2015:328196.

78. MacPherson H, Maschino AC, Lewith G, et al. Characteristics of acupuncture treatment associated
with outcome: an individual patient meta-analysis of 17,922 patients with chronic pain in randomised
controlled trials. PLoS One. 2013 Oct 11;8(10):e77438.

79. Madsen MV, Gotzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of
randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ.
2009 Jan 27;338:a3115.

80. Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DA, Berman BM, Bouter LM.
Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst Rev. 2010 Jan
20;(1):CD001977.

Page 15 of 20
Coverage Policy Number: 0024
 81. Manheimer E, Linde K, Lao L, Bouter LM, Berman BM. Meta-analysis: acupuncture for osteoarthritis of
the knee. Ann Intern Med. 2007 Jun 19;146(12):868-77.

82. Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain.
Ann Intern Med. 2005 Apr 19;142(8):651-63.

83. Mavrommatis CI, Argyra E, Vadalouka A, Vasilakos DG. Acupuncture as an adjunctive therapy to
pharmacological treatment in patients with chronic pain due to osteoarthritis of the knee: a 3-armed,
randomized, placebo-controlled trial. Pain. 2012 Aug;153(8):1720-6.

84. McCarney RW, Brinkhaus B, Lasserson TJ, Linde K. Acupuncture for chronic asthma. Cochrane
©
Database Syst Rev. In: The Cochrane Library, Issue 4. Copyright 2007 The Cochrane Collaboration.

85. McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy
interventions for temporomandibular disorders. Phys Ther. 2006 May;86(5):710-25.

86. Melchart D, Linde K, Fischer P, Berman B, White A, Vickers A, Allais G. Acupuncture for idiopathic
headache. Cochrane Database Systematic Reviews. In: The Cochrane Library, 2001 Issue 2.
©
Copyright 2009 The Cochrane Collaboration. Updated April 15, 2008.

87. Melchart D, Linde K, Fischer P, White A, Allais G, Vickers A, Berman B. Acupuncture for recurrent
headaches: a systematic review of randomized controlled trials. Cephalalgia. 1999 Nov;19(9):779-86;
discussion 765.

88. Melchart D, Thormaehlen J, Hager S, Liao J, Linde K, Weidenhammer W. Acupuncture versus placebo
versus sumatriptan for early treatment of migraine attacks: a randomized controlled trial. J Intern Med.
2003 Feb;253(2):181-8.

89. Meng CF, Wang D, Ngeow J, Lao L, Peterson M, Paget S. Acupuncture for chronic low back pain in
older patients: a randomized, controlled trial. Rheumatology (Oxford). 2003 Dec;42(12):1508-17.

90. Mayhew E, Ernst E. Acupuncture for fibromyalgia--a systematic review of randomized clinical trials.
Rheumatology (Oxford). 2007 May;46(5):801-4. Epub 2006 Dec 19.

91. Miller E, Maimon Y, Rosenblatt Y, Mendler A, Hasner A, Barad A, Amir H, Dekel S, Lev-Ari S. Delayed
Effect of Acupuncture Treatment in OA of the Knee: A Blinded, Randomized, Controlled Trial. Evid
Based Complement Alternat Med. 2009 Jan 5.

92. Molsberger AF, Mau J, Palwelec DB, Winkler J. Does acupuncture improve the orthopedic
management of chronic low back pain: a randomized, blinded, controlled trial with 3 months follow up.
Pain. 2002 Oct;99(3):579-87.

93. National Institutes of Health (NIH). Acupuncture. Consensus statement online. 1997 Nov
3-5;15(5):1-34. Accessed February 3, 2017. Available at URL address:
http://consensus.nih.gov/1997/1997Acupuncture107html.htm

94. National Institutes of Health (NIH). National Center for Complementary and Alternative Medicine
(NCCAM). Acupuncture. NCCAM Publication No. D003. Revised Dec, 2004. Updated January 16,
2016. Accessed February 5, 2016. Available at URL address: http://nccam.nih.gov/health/acupuncture/

95. National Institute of Health and Clinical Excellence. Acupuncture Evidence. May 22, 2012. Reviewed
2014, 2016. Accessed February 3, 2017. Available at URL address:
http://www.nhs.uk/Conditions/Acupuncture/Pages/Evidence.aspx

96. National Institute of Health and Clinical Excellence. Low back pain: early management of persistent
and non-specific low back pain. May 2009. Accessed February 5, 2016. Available at URL address:
http://www.nice.org.uk/Search?q=low+back+pain

Page 16 of 20
Coverage Policy Number: 0024
 97. Neri I, Airola G, Contu G, Allais G, Facchinetti F, Benedetto C. Acupuncture plus moxibustion to
resolve breech presentation: a randomized controlled study. J Matern Fetal Neonatal Med. 2004
Apr;15(4):247-52.

98. Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in adults. Cochrane
Database Syst Rev. 2011 Jan 19;1:CD007753.

99. Passalacqua G, Bousquet PJ, Carlsen KH, Kemp J, Lockey RF, Niggemann B, Pawankar R, Price D,
Bousquet J. ARIA update: I--Systematic review of complementary and alternative medicine for rhinitis
and asthma. J Allergy Clin Immunol. 2006 May;117(5):1054-62.

100. Prady SL, Thomas K, Esmonde L, Crouch S, Macpherson H. The natural history of back pain after a
randomised controlled trial of acupuncture vs usual care - long term outcomes. Acupunct Med. 2007
Dec;25(4):121-9.
st
101. Rakel D. Acupuncture for neck pain. In: Integrative medicine. 1 ed. Philadelphia, PA: W.B. Saunders
Company; 2003. p. 438.

102. Sangdee C, Teekachunhatean S, Sananpanich K, Sugandhavesa N, Chiewchantanakit S,

Pojchamarnwiputh S, Jayasvasti S. Electroacupuncture versus diclofenac in symptomatic treatment of
osteoarthritis of the knee: a randomized controlled trial. BMC Complement Altern Med 2002;2):3.

103. Scharf HP, Mansmann U, Streitberger K, Witte S, Kramer J, Maier C, Trampisch J, Victor N.
Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med. 2006 Jul
4;145(1):12-20.

104. Selfe TK, Taylor AG. Acupuncture and osteoarthritis of the knee: a review of randomized, controlled
trials. Fam Community Health. 2008 Jul-Sep;31(3):247-54.

105. Seshia SS, Wang SJ, Abu-Arafeh I, Hershey AD, Guidetti V, Winner P, Wöber-Bingöl C. Chronic daily
headache in children and adolescents: a multi-faceted syndrome. Can J Neurol Sci. 2010
Nov;37(6):769-78.

106. Smith CA, Hay PPJ. Acupuncture for depression. The Cochrane Database of Systematic Reviews
©
2004, Issue 3. Copyright 2007 The Cochrane Collaboration.

107. Smith CA, Carmady B. Acupuncture to treat common reproductive health complaints: An overview of
the evidence. Auton Neurosci. 2010 Oct 28;157(1-2):52-6.

108. Smith CA, Crowther CA. Acupuncture for induction of labour. Cochrane Database Systematic Reviews.
©
In: The Cochrane Library, 2004 Issue 4. Copyright 2007 The Cochrane Collaboration.

109. Smith C, Crowther C. The placebo response and effect of time in a trial of acupuncture to treat nausea
and vomiting in early pregnancy. Complement Ther Med. 2002 Dec;10(4):210-4.

110. Smith C, Crowther C, Beilby J. Acupuncture to treat nausea and vomiting in early pregnancy: a
randomized controlled trial. Birth. 2002 Mar;29(1):1-9.

111. Smith P, Mosscrop D, Davies S, Al-Ani Z. The efficacy of acupuncture in the treatment of
temporomandibular joint myofascial pain: A randomised controlled trial. J Dent. 2007 Mar;35(3):259-
67. Epub 2006 Nov 13.

112. Soderberg E, Carlsson J, Stener-Victorin E. Chronic tension-type headache treated with acupuncture,
physical training and relaxation training. Between-group differences. Cephalalgia. 2006
Nov;26(11):1320-9.

Page 17 of 20
Coverage Policy Number: 0024
 113. Standaert CJ, Friedly J, Erwin MW, Lee MJ, Rechtine G, Henrikson NB, Norvell DC. Comparative
effectiveness of exercise, acupuncture, and spinal manipulation for low back pain. Spine (Phila Pa
1976). 2011 Oct 1;36(21 Suppl):S120-30.

114. Suarez-Almazor ME, Looney C, Liu Y, et al. A randomized controlled trial of acupuncture for
osteoarthritis of the knee: effects of patient-provider communication. Arthritis Care Res (Hoboken)
2010;62(9):1229-1236.

115. Sun MY, Hsieh CL, Cheng YY, Hung HC, Li TC, Yen SM, Huang IS. The therapeutic effects of
acupuncture on patients with chronic neck myofascial pain syndrome: a single-blind randomized
controlled trial. Am J Chin Med. 2010;38(5):849-59.

116. Sun Y, Gan TJ. Acupuncture for the management of chronic headache: a systematic review. Anesth
Analg. 2008 Dec;107(6):2038-47.

117. Taechaarpornkul W, Suvapan D, Theppanom C, Chanthipwaree C, Chirawatkul A. Comparison of the

effectiveness of six and two acupuncture point regimens in osteoarthritis of the knee: a randomised
trial. Acupunct Med 2009;27(1):3-8.

118. Tait PL, Brooks L, Harstall C. Acupuncture: evidence from systemic reviews and meta-analyses. HTA
27: series A.. Health technology assessment. Alberta Heritage Foundation for Medical Research. 2002
Mar. Accessed February 3, 2017. Available at URL address:
http://www.ihe.ca/publications/acupuncture-evidence-from-systematic-reviews-and-meta-analyses

119. Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell, et al. Longer term clinical and
economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technol
Assess. 2005 Aug;9(32):iii-iv, ix-x, 1-109.

120. Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell MJ, Roman M, Walters SJ, Nicholl
J. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for
persistent non-specific low back pain. BMJ. 2006 Sep 23;333(7569):623.

121. Trigkilidas D. Acupuncture therapy for chronic lower back pain: a systematic review. Ann R Coll Surg
Engl. 2010 Oct;92(7):595-8.

122. Trinh K, Graham N, Gross A, Goldsmith C, Wang E, Cameron I, Kay T. Acupuncture for neck
disorders. Spine. 2007 Jan 15;32(2):236-43.

123. U.S. Food and Drug Administration (FDA). Acupuncture needles no longer investigational. Updates.
FDA Consumer. 1996 Jun;30(5). Accessed January 22, 2008. Available at URL address:
http://www.fda.gov/fdac/departs/596_upd.html

124. van Tulder MW, Cherkin DC, Berman B, Lao L, Koes BW. The effectiveness of acupuncture in the
management of acute and chronic low back pain. A systematic review within the framework of the
Cochrane Collaboration Back Review Group. Spine. 1999 Jun 1;24(11):1113-23.

125. Vas J, Aranda JM, Modesto M, Benítez-Parejo N, Herrera A, Martínez-Barquín DM, et al. Acupuncture
in patients with acute low back pain: a multicentre randomised controlled clinical trial. Pain. 2012
Sep;153(9):1883-9.

126. Vas J, Mendez C, Perea-Milla E, Vega E, Panadero MD, Leon JM, et al. Acupuncture as a
complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised
controlled trial. BMJ. 2004 Nov;329(7476):1216.

127. Vas J, Perea-Milla E, Méndez C, Sánchez Navarro C, León Rubio JM, Brioso M García Obrero I.
Efficacy and safety of acupuncture for chronic uncomplicated neck pain: a randomised controlled
study. Pain. 2006 Dec 15;126(1-3):245-55.

Page 18 of 20
Coverage Policy Number: 0024
 128. Vickers A. United Kingdom National Health Service (NHS) Centre for Reviews and Dissemination.
Acupuncture. Effective Health Bulletins. 2001 Nov;7(2):1-12. Accessed February 3, 2017. Available at
URL address: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743552/pdf/v011p00092.pdf
129. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al. Acupuncture for
chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012 Oct 22;172(19):1444-53.

130. Vickers AJ, Rees RW, Zollman CE, McCarney R, Smith CM, Ellis N, et al. Acupuncture of chronic
headache disorders in primary care: randomised controlled trial and economic analysis. Health
Technol Assess. 2004 Nov;8(48):1-50.

131. Wang LP, Zhang XZ, Guo J, Liu HL, Zhang Y, Liu CZ, et al. Efficacy of acupuncture for acute migraine
attack: a multicenter single blinded, randomized controlled trial. Pain Med. 2012 May;13(5):623-30.

132. Wang LP, Zhang XZ, Guo J, Liu HL, Zhang Y, Liu CZ, Yi JH, Wang LP, Zhao JP, Li SS. Efficacy of
acupuncture for migraine prophylaxis: a single-blinded, double-dummy, randomized controlled trial.
Pain. 2011 Aug;152(8):1864-71.

133. Weiner DK, Rudy TE, Morone N, Glick R, Kwoh CK. Efficacy of periosteal stimulation therapy for the
treatment of osteoarthritis-associated chronic knee pain: an initial controlled clinical trial. J Am Geriatr
Soc. 2007 Oct;55(10):1541-7.

134. Weidenhammer W, Linde K, Streng A, Hoppe A, Melchart D. Acupuncture for chronic low back pain in
routine care: a multicenter observational study. Clin J Pain. 2007 Feb;23(2):128-35.

135. White AR, Ernst E. A systemic review of randomized controlled trials of acupuncture for neck pain.
Rheumatology (Oxford). 1999 Feb;38(2):143-7.

136. White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: a
systematic review. Rheumatology (Oxford). 2007 Mar;46(3):384-90.

137. White P, Lewith G, Prescott P, Conway J. Acupuncture versus placebo for the treatment of chronic
mechanical neck pain: a randomized, controlled trial. Ann Intern Med. 2004 Dec;141(12):911-9.

138. White AR, Rampes H, Ernst E. Acupuncture for smoking cessation. Cochrane Database Systematic
©
Reviews. In: The Cochrane Library, 2005 Issue 4. Copyright 2007The Cochrane Collaboration.

139. White AR, Resch KL, Chan JC, Norris CD, Modi SK, Patel JN, Ernst E. Acupuncture for episodic
tension-type headache: a multicentre randomized controlled trial. Cephalalgia. 2000 Sep;20(7):632-7.

140. Williamson L, Wyatt MR, Yein K, Melton JT. Severe knee osteoarthritis: a randomized controlled trial of
acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting
knee replacement. Rheumatology (Oxford). 2007 Sep;46(9):1445-9.

141. Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K, Willich SN. Acupuncture in patients with
osteoarthritis of the knee or hip: a randomized, controlled trial with an additional nonrandomized arm.
Arthritis Rheum. 2006 Nov;54(11):3485-93.

142. Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K, Willich SN. Acupuncture for patients with
chronic neck pain. Pain. 2006 Nov;125(1-2):98-106.

143. Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil S, et al. Acupuncture in patients with
osteoarthritis of the knee: a randomised trial. Lancet. 2005 Jul 9-15;366(9480):136-43.

144. Wonderling D, Vickers AJ, Grieve R, McCarney R. Cost effectiveness analysis of a randomised trial of
acupuncture for chronic headache. BMJ. 2004 Mar 27;328(7442):747.

Page 19 of 20
Coverage Policy Number: 0024
 145. World Health Organization (WHO). Medicines documentation. Acupuncture: Review and analysis of
reports on controlled clinical trials. WHO; 2003. Accessed February 3, 2017. Available at URL address:
http://apps.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=93&codcch=196

146. Yao E, Gerritz PK, Henricson E, Abresch T, Kim J, Han J, Wang K, Zhao H. Randomized controlled
trial comparing acupuncture with placebo acupuncture for the treatment of carpal tunnel syndrome. PM
R. 2012 May;4(5):367-73.

147. Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese medicine for neck pain and low back
pain: a systematic review and meta-analysis. PLoS One. 2015 Feb 24;10(2):e0117146.

148. Yuan QL, Wang P, Liu L, et al. Acupuncture for musculoskeletal pain: A meta-analysis and meta-
regression of sham-controlled randomized clinical trials. Sci Rep. 2016 Jul 29;6:30675.

149. Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of acupuncture for low
back pain: a systematic review. Spine. 2008 Nov 1;33(23):E887-900.

150. Zhang QH, Yue JH, Liu M, Sun ZR, Sun Q, Han C, Wang D. Moxibustion for the Correction of
Nonvertex Presentation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Evid Based Complement Alternat Med. 2013;2013:241027.

151. Zhang SH, Liu M, Asplund K, Li L. Acupuncture for acute stroke. The Cochrane Database of
©
Systematic Reviews 2005, Issue 2. Copyright 2007 The Cochrane Collaboration.

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