On January 21, 2020, CMS released a final decision covering acupuncture. The final decision provides coverage to anyone with " chronic back pain" (not further defined, but not due to "systematic cause" like metastatic disease). 12 visits in 90 days are covered. An additional 8 visits can be covered if the therapy is working. A capped number of 20 visits per year are covered.
Two notable points - first, the decision was late; it was due in October. Second, the draft decision in July had placed acupuncture under limited coverage with evidence development (coverage only in trials).
CMS Press Release Quotes
Secr. Alex Azar:
“Expanding options for pain treatment is a key piece of the Trump Administrations’ strategy for defeating our country’s opioid crisis,” said HHS Secretary Alex Azar. “President Trump has promised to protect and improve Medicare for our seniors, and deciding to cover this new treatment option is another sign of that commitment. Medicare beneficiaries will now have a new option at their disposal to help them deal with chronic low back pain, which is a common and sometimes debilitating condition.”Deputy Administrator Kimberly Brandt:
“We are dedicated to increasing access to alternatives to prescription opioids and believe that covering acupuncture for chronic low back pain is in the best interest of Medicare patients.”
Administrator Seema Verma and Coverage Group leaders were not associated with quotes.
Opioid Policy
The NCD specifically cites Trump administration policy on the opioid crisis and the need for alternative therapies. CMS also cites coverage of acupuncture to one degree or another by the VA and some private insurers.
CMS writes, "We believe that in light of the relative safety of the procedure and the grave consequences of the opioid crisis in the United States, there is sufficient rationale to provide this nonpharmacologic treatment to appropriate beneficiaries with chronic low back pain."
Uses of acupuncture for other conditions than lower back pain remain non-covered.
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Coding and Payment
There are existing AMA CPT codes for acupuncture - 97810, 97811 for first and second 15 minutes. They are priced at around $28 and $38 respectively (higher in cities). Up til now, those two codes been categorized as nationally non-payable (non-processable) by CMS.
Historically, it often takes over six months for CMS to issue claims processing instructions on new NCDs. I would expect CMS will remove these codes from "rejection" status faster in this case.
CMS could elect to create and use other codes (G-codes) for the NCD. I recall at 2019 recent AMA CPT meeting there were some extensive changes, additions, or Category III codes under debate in this area discussed. I didn't track if they passed or not.
Incident-To
Individuals with only a state healthcare acupuncture credential can't enroll for payment from Medicare. Acupuncture has to be administered by (or under direct supervision of) someone who can enroll in Medicare, e.g. a doctor or nurse practitioner.
Normally CMS has pretty vague rules about who can perform services incident-to a physician (e.g. "appropriate" personnel.) Here, the incident-to person must be a state licensed acupuncturist. (See the NCD for full details and see the Q&A public comments section).
A chiropractor under Medicare law can only be paid for spine manipulation, but he/she could be paid for acupuncture if he/she was also (in parallel) a licensed acupuncturist and under the supervision of a physician.
Coverage with Evidence Development
The draft NCD last summer proposed coverage with evidence development; as far as I saw, there is no mention of the proposal in the final decision, it's just gone and replaced.
