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National Coverage Determination (NCD)

Acupuncture for Chronic Lower Back Pain (cLBP)

30.3.3

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Tracking Information

Publication Number
100-3
Manual Section Number
30.3.3
Manual Section Title
Acupuncture for Chronic Lower Back Pain (cLBP)
Version Number
1
Effective Date of this Version
01/21/2020
Ending Effective Date of this Version
Implementation Date
06/24/2020
Implementation QR Modifier Date

Description Information

Benefit Category
Incident to a physician's professional Service
Inpatient Hospital Services
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

A. General

Acupuncture is the selection and manipulation of specific acupuncture points by a variety of needling and non-needling techniques.
Indications and Limitations of Coverage

B. Nationally Covered Indications

Effective for services performed on or after January 21, 2020, CMS will cover acupuncture for Medicare patients with chronic Lower Back Pain (cLBP). Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstance:

  • For the purpose of this decision, cLBP is defined as:
    • Lasting 12 weeks or longer;
    • nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc.disease);
    • not associated with surgery; and,
    • not associated with pregnancy.
  • An additional 8 sessions will be covered for those patients demonstrating an improvement.
  • No more than 20 acupuncture treatments may be administered annually
  • Treatment must be discontinued if the patient is not improving or is regressing.

Physicians (as defined in 1861(r)(1) of the Social Security Act (the Act) may furnish acupuncture in accordance with applicable state requirements.

Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs) (as identified in 1861(aa)(5) of the Act), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:

  • a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and,
  • a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, PA, or NP/CNS required by our regulations at 42 CFR §§ 410.26 and 410.27.

C. Nationally Non-Covered Indications

All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.

D. Other

N/A

(This NCD last reviewed January 2020.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
10128
Coverage Transmittal Link
https://www.cms.gov/files/document/r10128NCD.pdf
Revision History

10/2024 - The purpose of the Change Request (CR) is to provide a quarterly maintenance update of ICD-10 coding conversions and other coding updates specific to National Coverage Determinations(NCDs). No policy is being changed as a result of these updates. (TN 12903) (CR13818)

08/2022 - Transmittal 11545 dated August 5, 2022, is being rescinded and replaced by Transmittal 11584, dated, August 31, 2022. (TN 11584) (CR12822)

08/2022 - The purpose of this Change Request (CR) is to provide a maintenance update of ICD-10 conversions and other coding updates to specific NCDs. (TN 11545) (CR12822)

04/2022 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. (TN 11391) (CR12606)

04/2022 - Transmittal 11264, dated February 10, 2022, is being rescinded and replaced by Transmittal 11342, dated, April 6, 2022 to (1) revise BR 12606.10 instructions for NCD 110.24, (2) BR12606.2, fix typo in NCD 160.18 spreadsheet ICD-10 G40.384, which should be G40.834, and, (3) revise implementation verbiage (no changes to the actual implementation date). All other information remains the same. (TN 11342) (CR12606)

02/2022 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.(TN 11264) (CR12606)

01/2022 - Transmittal 11068, dated October 21, 2021, is being rescinded and replaced by Transmittal 11179, dated, January 12, 2022 to revise the attachment for NCD 110.24, CAR-T, to add business requirement 12480.10.1 by adding generic unspecified procedure codes, to clarify coverage and claims processing in the policy section and to review the implementation date. All other information remains the same. (TN 11179) (CR12480)

10/2021 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. (TN 11068) (CR12480)

05/2021 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. (TN 10817) (CR12279)

08/2020 - Transmittal 10128, dated May 8, 2020, is being rescinded and replaced by Transmittal 10337, dated, August 27, 2020, to change business requirement 11755-04.2.1.1 to deny claims and provides revised messaging. The Claims Processing Manual at section 410.4 has been revised accordingly. All other information remains the same. (TN 10337) (CR11755)

05/2020 - The purpose of this change request is to inform MACs that CMS will cover acupuncture for chronic low back pain (cLBP) effective for claims with dates of service on and after January 21, 2020. (TN 10128) (CR11755)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Acupuncture for Chronic Lower Back Pain (cLBP) 1 01/21/2020 - N/A You are here
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CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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