Medicare Now Covers Acupuncture for Chronic Low Back Pain

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

The Centers for Medicare & Medicaid Services (CMS) will cover acupuncture for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:

  • For the purpose of this decision, chronic low back pain (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 eight 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)) may furnish acupuncture in accordance with applicable state requirements.

Physician assistants, nurse practitioners/clinical nurse specialists (as identified in 1861(aa)(5)), 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
  • 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, physician assistant, or nurse practitioner/clinical nurse specialist required by our regulations at 42 CFR §§ 410.26 and 410.27.”

This decision was posted January 21, 2020.  There’s a great deal of information in this coverage decision, including some additional suggestions for chronic low back pain relief.  It’s worth the read.  Note that at the top of the decision, there’s an option to print as a PDF.  That may be easier to read.

The Press Release provides background to this important reconsideration and in part, some of the reasons for the NCD change:

“Today the Centers for Medicare & Medicaid Services (CMS) finalized a decision to cover acupuncture for Medicare patients with chronic low back pain. Before this final National Coverage Determination (NCD) reconsideration, acupuncture was nationally non-covered by Medicare. CMS conducted evidence reviews and examined the coverage policies of private payers to inform today’s decision.

“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.”

The decision regarding coverage takes into account an assessment of benefits and harms and the opioid public health crisis.  While a small number of adults 65 years of age or older have been enrolled in published acupuncture studies, patients with chronic low back pain in these studies showed improvements in function and pain.  The evidence reviewed for this decision supports clinical strategies that include nonpharmacologic therapies for chronic low back pain. CMS notes too that while there is variation in covered indications and frequency of services, a number of large private payers provide some coverage of acupuncture for certain indications.

“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,” said CMS Principal Deputy Administrator of Operations and Policy Kimberly Brandt. “We are building on important lessons learned from the private sector in this critical aspect of patient care. Over-reliance on opioids for people with chronic pain is one of the factors that led to the crisis, so it is vital that we offer a range of treatment options for our beneficiaries.”

I encourage you to review this coverage decision and share it with your IDT team, including physicians and physician extenders.  It provides another option for Medicare beneficiaries to receive pain relief in the face of the current and ongoing opioid public health crisis.