Review of Acupuncture in WCMSA Determinations

March 4, 2020 –

As noted in our prior NuQuest blog which can be found at https://mynuquest.com/cases-points-blog/new-cms-coverage-determination/, CMS issued a Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N) (Decision Memo).  Effective January 21, 2020, CMS noted that acupuncture would be covered for treatment of chronic low back pain in certain circumstances.  Since that time, NuQuest has monitored all CMS Workers’ Compensation Medicare Set-Aside (WCMSA) approval letters to determine how this type of treatment would be included in WCMSA allocations. In early February 2020, CMS issued an approval letter on a WCMSA submission that included twenty (20) sessions of acupuncture for a diagnosis of right shoulder pain. However, the Decision Memo states all types of acupuncture including dry needling for any conditions other than chronic low back pain is not Medicare covered and should not have been included in the allocation. On February 25, 2020 CMS issued a WCMSA approval letter that also included twenty (20) sessions of acupuncture over the claimant’s 16-year life expectancy for a diagnosis of chronic low back pain. This inclusion was warranted based upon a review of the medical records and the criteria for coverage listed in the Decision Memo.  We will continue to monitor how this treatment modality is being included in the WCMSA approvals to determine whether inclusion was proper or a CMS error.  Should you have any questions regarding this or for any of your Medicare compliance needs, please contact the Settlement Consultant Team.