New CMS Coverage Determination

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January 23, 2020 –

On January 21, 2020, CMS issued a decision memo for coverage of acupuncture treatments for the treatment of chronic low back pain.  Specifically, the Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N) states in pertinent parts as follows:

A.  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.

NuQuest will continue to monitor this development to determine if and how CMS will include this line of treatment in Workers’ Compensation Medicare Set-Aside allocations.  In addition, even if the claimant is receiving acupuncture for chronic low back pain, there are still certain requirements that must be met in order for this treatment to be covered by CMS.  Monitoring the type of treatment, effectiveness of treatment and the individual providing treatment will be key in potentially disputing and excluding this cost from the WCMSA.  Should you have any questions regarding this development or for any of your Medicare Secondary Payer compliance needs, please contact us.