Guideline/Procedure Title: Acupuncture Services Guidelines / ☒ External Policy
☐ Internal Policy /
Original Date: 02/16/1995 / Next Review Date: 11/16/2017
Last Review Date: 11/16/2016 /
Applies to: / ☒ Medi-Cal / ☐ Healthy Kids / ☐ Employees /
Guideline/Procedure Number: MCUG3002 (previously UG100302) / Lead Department: Health Services /
Guideline/Procedure Title: Acupuncture Services Guidelines / ☒External Policy
☐ Internal Policy /
Original Date: 02/16/1995 / Next Review Date: 11/16/2017
Last Review Date: 11/16/2016 /
Applies to: / ☒ Medi-Cal / ☐ Healthy Kids / ☐ Employees /
Reviewing Entities: / ☒ IQI / ☐ P & T / ☒ QUAC /
☐ OPerations / ☐ Executive / ☐ Compliance / ☐ Department /
Approving Entities: / ☐ BOARD / ☐ COMPLIANCE / ☐ FINANCE / ☒ PAC
☐ CEO / ☐ COO / ☐ Credentialing / ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH / Approval Date: 11/16/2016
I. RELATED POLICIES:
A. MCUP3124 - Referral to Specialists (RAF) Policy
B. MCUP3041 - TAR Review Process
II. IMPACTED DEPTS:
A. Health Services
B. Member Services
C. Claims
III. DEFINITIONS:
N/A
IV. ATTACHMENTS:
N/A
V. PURPOSE:
This guideline describes the conditions under which acupuncture services are authorized and the procedure providers follow to obtain such authorization.
VI. GUIDELINE / PROCEDURE:
A. Acupuncture services are a Partnership HealthPlan of California (PHC) benefit if the member meets medical necessity criteria.
B. Covered Services:
1. Acupuncture services for members under age 21 are generally authorized to relieve certain painful conditions such as dysmenorrhea, low back pain, or chronic head pain.
2. Acupuncture services for members age 21 and over are limited to the following:
a. Treatment of pain lasting 6 weeks or more of the following types: back pain, osteoarthritis of the hip or knee, migraine headache.
C. A physician or certified acupuncturist must be qualified to render acupuncture services. Services are not reimbursed when billed as part of an emergency or inpatient service. Services are not reimbursed if rendered by a physician assistant, nurse practitioner, or certified nurse midwife. Non-acupuncture services rendered by a certified acupuncturist will not be reimbursed.
D. The Primary Care Provider (PCP) must refer the member to the acupuncturist for an initial evaluation only, using a Referral Authorization Form (RAF). Special case managed members can be referred for one consultation visit through a physician order. After the acupuncture provider has completed the initial evaluation, a treatment plan is developed.
E. A Treatment Authorization Request (TAR) must be submitted to PHC by the acupuncturist who indicates the services requested. The request must include the description of medical need and a copy of the treatment plan. The treatment plan must include clinical justification for the proposed treatment and the following information:
1. Medical diagnosis necessitating the service with a summary of the member’s medical condition
2. Dates and length of treatment
3. Therapeutic goals of treatment
4. Dates of planned progress review
F. The Utilization Management (UM) staff reviews the TAR for medical necessity and will consult with the referring physician or acupuncturist as indicated. The definition of "medical necessity" states that necessary health care services are those needed to protect life, to prevent significant illness or significant disability, or to alleviate pain.
G. The UM nurse may approve the initial TAR request for up to 12 visits at any frequency for up to 6months, provided medical necessity has been demonstrated. No more than 12 visits every 6 months will be approved.
H. The maximum length of acupuncture services covered in a 24 hour period is 45 minutes.
I. Acupuncture CPT codes 97810 through 97814 are covered under this policy. In addition, initial assessments may be billed using CPT code 99202.
VII. REFERENCES:
A. Medi-Cal Guidelines
VIII. DISTRIBUTION:
A. PHC Departmental Directors
B. PHC Provider Manual
IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X. REVISION DATES:
04/28/00; 09/19/01; 10/16/02; 09/15/04; 09/21/05; 10/17/07; 10/15/08; 01/21/09; 04/21/10; 01/18/12; 10/15/14; 02/18/15; 05/20/15; 08/19/15; 05/18/16; 11/16/16
PREVIOUSLY APPLIED TO: N/A
*********************************
In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:
· Consistent with sound clinical principles and processes
· Evaluated and updated at least annually
· If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.
Page 2 of 2