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National Coverage Determination (NCD)

Acupuncture for Fibromyalgia

30.3.1

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Tracking Information

Publication Number
100-3
Manual Section Number
30.3.1
Manual Section Title
Acupuncture for Fibromyalgia
Version Number
2
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

N/A for acupuncture for fibromyalgia.

C. Nationally Non-Covered Indications

Effective for claims with dates of service on and after April 16, 2004, after careful reconsideration of its initial non-coverage determination for acupuncture, the Centers for Medicare & Medicaid Services (CMS) concludes that there is no convincing evidence for the use of acupuncture for pain relief in patients with fibromyalgia. Study design flaws presently prohibit assessing acupuncture’s utility for improving health outcomes. Accordingly, CMS determines that acupuncture is not considered reasonable and necessary for the treatment of fibromyalgia within the meaning of §1862(a)(1) of the Social Security Act, and the national non-coverage determination for acupuncture for fibromyalgia continues.

D. Other

N/A

(This NCD last reviewed April 2004.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
10128
Coverage Transmittal Link
https://www.cms.gov/files/document/R10128NCD.pdf
Revision History

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)

04/2004 - Noncoverage for acupuncture continued. Effective and implementation dates 04/16/2004. (TN 11) (CR 3250)
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 Fibromyalgia 2 01/21/2020 - N/A You are here
Acupuncture for Fibromyalgia 1 04/16/2004 - 01/21/2020 View
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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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