Acupuncture is a traditional form of Chinese medical treatment that has been practiced for over 3,000 years.

Acupuncture is the practice of piercing the skin with needles at specific body sites to induce anesthesia, to relieve pain to alleviate withdrawal symptoms of substance abusers, or to treat various non-painful disorders. In acupuncture, the placement of needles into the skin is dictated by the location of meridians. These meridians are thought to mark patterns of energy flow throughout the human body. Acupuncture has 4 components—the acupuncture needle(s), the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle. Acupuncture may be performed with or without electrical stimulation.

The U.S. Food and Drug Administration (FDA) has cleared acupuncture needles for marketing. The needles used in acupuncture, when intended for general use in “the performance of acupuncture,” have been classified by the FDA to Class II devices ( The Gray Sheet, April 8, 1996). The order states that “clinical studies and preclinical animal studies constitute valid scientific evidence in support of the clinical effectiveness of acupuncture needles for the performance of acupuncture treatment.”

Acupuncture may be considered medically necessary for treatment of nausea associated with surgery, chemotherapy, and pregnancy.

Acupuncture for any other indication, including but not limited to acupuncture for the treatment of pain, is considered investigational.

BlueCard/National Account Issues

Acupuncture is considered within the scope of practice of a licensed physician. However, some physicians may seek additional training in acupuncture. Non-physicians who have completed appropriate training may also be licensed to perform acupuncture. State regulations may affect the range of providers offering acupuncture.

This policy was originally based on a 1996 TEC Assessment (1) of acupuncture for the treatment of pain. The evidence did not clearly show that the effects of acupuncture exceed placebo effects.

The following study selection criteria were used in the 1996 TEC Assessment:

• The study included a control group that was given a treatment intended to serve as a placebo control, and was compared with active acupuncture treatment.
• The study selected a clinical sample, not healthy volunteers.

Various control treatments were used in the studies reviewed in the 1996 TEC Assessment. Some performed acupuncture outside the traditional meridians; these studies generally did not find an advantage of acupuncture performed by the prescribed method. Other studies used low- or no-needle insertion, and still others used low stimulation. These studies provided more mixed results, but it was unclear whether studies using better quality methods consistently found active acupuncture to produce better results than control acupuncture.

2002 Update

National Institutes of Health Consensus Development Panel

In November 1997, a National Institutes of Health Consensus Development Panel (NIHCDP) met to discuss acupuncture. The Consensus Statement (2) concluded that evidence clearly shows that needle acupuncture is efficacious in treating nausea secondary to surgery or chemotherapy in adults, and probably effective for nausea of pregnancy as well. The document also states that there is evidence of efficacy for postoperative dental pain. The Panel made a more equivocal statement that acupuncture "may be useful" in the following conditions: addiction, stroke rehabilitation, headache, menstrual cramps, lateral elbow pain, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma.

Systematic reviews have been published that confirm the NIHCDP conclusions on nausea due to surgery, chemotherapy, and labor. In 1996, Vickers (3) identified 33 controlled trials of acupuncture for antiemesis. Four studies found that acupuncture was no more effective than control when performed during anesthesia, while 27 of the other 29 studies found acupuncture to be more effective than control. Higher quality studies also consistently found acupuncture to have an antiemetic effect. A later meta-analysis of postoperative nausea and vomiting (4) concluded that acupuncture could be offered as an alternative to antiemetic drugs.

Two studies were cited in the NIHCDP report of acupuncture for postoperative dental pain. Sung et al (5) included 40 patients assigned to 4 groups, receiving both an analgesic and acupuncture, each in either active or placebo forms. Codeine plus active acupuncture was superior in pain relief to all other conditions, but placebo drug plus active acupuncture did not differ from both placebo conditions. These findings have not been replicated. Lao et al (6) compared active and placebo acupuncture in 19 subjects, finding longer duration of anesthesia in the active group. These authors published another study on a slightly larger sample (7), but independent replication of these findings has not been published yet. A literature search did not identify additional controlled trials. The available evidence on postoperative dental pain is insufficient to permit conclusions about whether the effects of acupuncture exceed those of placebo.

Cochrane Database of Systematic Reviews Search/MEDLINE Search Update

The Cochrane Library lists 7 Cochrane Reviews on the use of acupuncture for the following conditions: low back pain, idiopathic headache, lateral elbow pain, rheumatoid arthritis, induction of labor, asthma, and smoking cessation. This update addresses those conditions, in addition to chronic pain other than low back pain or headache, stroke rehabilitation, and addictions other than tobacco. For conditions not represented by Cochrane Reviews, studies cited in the NIHCDP report were reviewed in addition to systematic reviews, and studies published since 1996 were sought. Online search updates were performed on the MEDLINE database. The dates covered in the searches were January 1996 through August 2002.

Low Back Pain

A 1999 Cochrane Review on acupuncture for low back pain was completed by van Tulder et al (8) It included 11 randomized trials, only 2 of which were of high methodologic quality. The paper concluded that evidence was limited that acupuncture is more effective than placebo. A meta-analysis by Ernst and White (9) found that evidence is insufficient to state whether acupuncture is superior to placebo. Two trials appearing since these analyses report conflicting results. Carlsson and Sjolund (10) found better outcomes in patients receiving active acupuncture compared with placebo, while Leibing et al (11) found no difference between active and placebo acupuncture.

Idiopathic Headache

Melchart et al (12) selected 26 controlled trials of acupuncture for idiopathic headache. Sixteen studies compared active and sham acupuncture. The authors noted that the majority of studies had methodologic and/or reporting flaws. They concluded that the quality and quantity of evidence are not fully convincing. Since the most recent update to the Cochrane Review, no additional placebo-controlled trials on the use of acupuncture for headache were identified in the literature search.

Lateral Elbow Pain

Green et al (13) reviewed the use of acupuncture for lateral elbow pain. Reviewers found 4 small, randomized trials that had study design flaws. The report concluded that the evidence is insufficient to either support or refute the use of acupuncture for this condition. A study postdating the last update to Cochrane Review on this use of acupuncture was published by Fink et al. (14) The study found that, compared with placebo acupuncture, active acupuncture achieved better results in pain and function at 2 weeks, but only function was still better at 2 months. The study included only 22 patients and is insufficient to overcome the overall methodologic flaws and inconsistent results of the whole evidence base.

Rheumatoid Arthritis

Casimiro et al (15) performed the Cochrane Review on acupuncture for rheumatoid arthritis. Only 2 controlled trials were found, using different acupuncture methods. One study found acupuncture no more effective than placebo, while the other reported an advantage in knee pain for acupuncture at 24 hours. This evidence is clearly insufficient to permit conclusions about the effects of acupuncture on rheumatoid arthritis. The literature search found no studies appearing since the last update to the Cochrane Review on this topic.

Other Chronic Pain

The NIHCDP report concluded that acupuncture may be helpful for the following pain conditions: menstrual cramps, fibromyalgia, myofascial pain, osteoarthritis, and carpal tunnel syndrome. Two meta-analyses of acupuncture for chronic pain were cited in the NIHCDP report, (16, 17) both of which stated that the evidence did not support conclusions about the efficacy of acupuncture, relative to placebo, for chronic pain. Recent systematic reviews make the same observation on the use of acupuncture for general chronic pain, (18) knee osteoarthritis, (19) fibromyalgia, (20) and myofascial pain. (21)

Induction of Labor

The Cochrane Review on acupuncture for the induction of labor was conducted by Smith and Crowther. (22) The review found no randomized trials meeting study quality standards comparing acupuncture with placebo, no treatment, or alternative treatments. The literature search found no studies appearing since the last update to the Cochrane Review on this topic.

Chronic Asthma

Linde et al(23) reviewed use of acupuncture for chronic asthma. Study selection criteria were met by 7 trials. The reviewers concluded that no statistically significant or clinically relevant effects have been found in comparisons of active and sham acupuncture. They stated further that evidence is insufficient to make recommendations about the value of acupuncture in asthma treatment. The literature search identified 2 randomized trials published since the most recent update to the Cochrane Review. Both studies found that active acupuncture did not differ from placebo acupuncture. (24, 25)

Smoking Cessation

Acupuncture for smoking cessation was reviewed by White et al in 2002. (26) The authors found 22 randomized trials. Of these, none found active acupuncture to be superior to placebo acupuncture at any time interval. The literature search found no studies appearing since the last update to the Cochrane Review on this topic.

Other Addictions

The NIHCDP report cites 3 studies on addictions other than tobacco. One study published initial pilot results and 6-month follow-up for a comparison of active and sham acupuncture in 80 severe recidivist alcoholics. (27, 28) Control patients had higher rates of drinking episodes and admissions to detoxification centers than patients treated with active acupuncture. This was a single-blind study that has not been replicated. A study of 321 patients entered in an outpatient substance abuse program was cited in the NIHCDP report, but it did not include a placebo acupuncture group (29), nor did a study of cocaine dependence. (30) A recent study comparing active and sham acupuncture for both inpatient and outpatient treatment of cocaine abuse failed to find significant effects favoring active acupuncture. (31)

Stroke Rehabilitation

The NIHCDP report cited only 1 study comparing active and sham acupuncture for stroke rehabilitation. (32) Response to active treatment was rated as good in 4 of 10 patients, compared with 0 of 6 placebo group patients. A recent study (33) compared acupuncture with low-intensity control electrostimulation and found no significant effects favoring acupuncture in functional outcome or quality of life. These studies are clearly insufficient to demonstrate the effectiveness of acupuncture for stroke rehabilitation.

2005 Update

A review of the literature for the period of 2004 through April 2005 identified several additional randomized placebo-controlled trials of the role of acupuncture in treating osteoarthritis and other conditions. However, these studies report conflicting results, and the interpretation of the trials reporting positive results are limited due to methodologic flaws in the trial. Therefore, the policy statement is unchanged. The following discussion reviews these trials in detail.

Berman and colleagues reported on a study of 570 patients with osteoarthritis. Patients were randomized to receive a 26-week course of gradually tapering true acupuncture or the same schedule of sham acupuncture. (34) An additional group received educational sessions, consisting of two 6-hour group sessions. The primary outcome measures were WOMAC pain and function scores at 8 and 26 weeks. On follow-up, those in the true acupuncture group experienced greater improvement in WOMAC function scores at 8 weeks compared to sham group, but pain score was only significantly better at 14 and 26 weeks. However, the major limitation in this study was the large number of dropouts: 25.3% for true acupuncture, 23.0% for sham acupuncture, and 37.9% for the education group. The Technology Evaluation Center, in applying study quality criteria developed by the U.S. Preventive Services Task Force considers any study with a >20% dropout rate to be of “poor” quality. In addition, the published study does not provide adequate detail to determine the impact of the missing data on the reported outcomes. The authors state that they performed a multiple data imputation analysis using 5 randomly drawn imputations. The details of this process are not described, but the authors conclude that the results of the multiple imputation analysis were very similar to those that used nonimputed data. A more informative approach would be to perform sensitivity analyses using different assumptions about the missing data. For example, a rigorous test of sensitivity would be to assume that all the dropouts in the active treatment group were failures, while all the dropouts in the control groups were successes.

Vas and colleagues reported on the results of a trial that randomized 97 patients with osteoarthritis of the knee to receive either acupuncture or placebo acupuncture with diclofenac. (35) Patients were treated for 12 weeks, when the final assessment was made. A total of 9 patients dropped out of the study. The primary outcome measure was changes in the WOMAC index and pain levels, using an intent-to-treat analysis, assigning the 1 dropout in the treatment group the worst score for the treatment group as a whole, while the 8 dropouts in the control group were assigned the best scores for the control group. There was a greater reduction in the WOMAC index in the treatment group compared to the control (mean difference between the 2 groups = 23.9%). The study is limited in that there was no attempt to determine the success of the blinding and the short-term follow-up of 12 weeks.

Other randomized studies by Vickers and coworkers and Kvorning et al, focusing on chronic headache and pregnancy- associated back pain, respectively, did not include a sham acupuncture control group, limiting any interpretation of results. (36,37) Randomized studies by White and colleagues and Streitberger and colleagues of patients with chronic neck pain and postoperative nausea and vomiting, respectively, reported that acupuncture provided no additional benefit compared to placebo acupuncture. (38, 39) Finally, Stener-Victorin and colleagues conducted a study of 45 patients with hip osteoarthritis awaiting hip replacement surgery who were randomized to receive either hydrotherapy, electro acupuncture, or education. While positive results of both electro acupuncture and hydrotherapy were reported compared to no changes in the education group, the small numbers in each group (n=15) require confirmation in larger studies. (40)

2006 Update

A literature search was conducted for the period from April 2005 through July 2006 for this update. A number of additional Cochrane Reviews and important clinical studies have been published in that time. In reviewing clinical studies, whether or not a sham acupuncture treatment was used is noted in the summaries.

Stroke Rehabilitation

Acupuncture has been used as a treatment for patients with strokes for many years in China. This Cochrane Review was to assess the efficacy and safety of acupuncture for patients with stroke in the subacute or chronic stages. (41) Five randomized clinical trials were found through November 2005: however, the methodological quality was considered inadequate in all. The authors concluded that there is currently no clear evidence on the effects of acupuncture on subacute or chronic stroke.

Epilepsy

A Cochrane Review of use of acupuncture in patients with epilepsy found only 3 small randomized trials of varying methodological quality and short follow-up. (42). The authors concluded that current evidence does not support acupuncture as a treatment for epilepsy.

Neck Disorders

Another Cochrane Review focused on acupuncture for chronic (> 3 months) neck disorders. (43) While the review concluded that there was moderate evidence to support the use of acupuncture in these patients, the data to support this indication seem limited. Because the total review involved only 661 participants, because there were methodological concerns with most studies, and because outcomes for this chronic condition were just measured at the end of treatment, additional studies are needed. Witt and colleagues reported on use of acupuncture for patients with chronic neck pain. (44) While improvement was seen compared to the control group receiving usual care, the lack of a sham acupuncture comparison group raises questions about these results.

Osteoarthritis (Knee)

Scharf and colleagues found that compared with physiotherapy and as-needed anti-inflammatory drugs, addition of traditional Chinese acupuncture (TCA) or sham acupuncture (10 to 15 treatments) to the conservative regimen led to greater improvement in WOMAC scores at 26 weeks among 1,007 patients with chronic osteoarthritis of the knee. (45) Approximately half of the 2 “acupuncture” groups had at least a 36% improvement in their WOMAC score. No statistically significant difference was observed between TCA and sham acupuncture groups. In contrast, Witt and colleagues found that acupuncture (12 treatments over 8 weeks) was superior to both sham acupuncture and no treatment when measured at 8 weeks in a group of 294 patients with osteoarthritis of the knee. (46) At 52 weeks, the difference between acupuncture and sham acupuncture was not statistically significant.

Low Back Pain

Brinkhaus and colleagues reported findings similar to Scharf in a study of 298 patients with low-back pain. (47) Compared with a waiting-list group, there was no statistically significant difference in the change in intensity of low back pain at 8 weeks for those who received acupuncture compared to a group that received “minimal” acupuncture (superficial needling at non-acupuncture points.) Changes in the visual analogue scale (VAS) at 8 weeks for the 3 groups were 6.9 mm, 28.7 mm, and 23.6 mm, respectively. Thomas and colleagues evaluated acupuncture vs. usual care (no sham acupuncture) in 239 patients with low back pain. (48) While acupuncture had a significant impact on bodily pain, there was no impact on function and disability. Given the lack of a sham treatment group and lack of impact on outcomes other than pain, this study provides very limited support for acupuncture for this indication.

Fibromyalgia

In a study of 100 patients with fibromyalgia, Assefi reported no difference in pain scores for patients who received acupuncture compared to those who received various sham acupuncture treatments. (49) In a second partially-blinded small (N=51) study in patients with fibromyalgia, investigators found that fatigue and anxiety were the most improved symptoms with treatment, but that activity and physical function levels did not change for acupuncture compared with simulated acupuncture. (50) Given these conflicting results, larger controlled studies are needed to further explore the impact of treatment on various outcomes.

Headache

Melchart and colleagues reported that an acupuncture intervention was more effective than no treatment, but not significantly more effective than minimal (superficial needling at non-acupuncture sites) acupuncture, for the treatment of 270 patients with tension-type headaches. (51) They measured both differences in number of days with headache and the proportion of patients with at least a 50% decrease in the number of days with headache. Linde and colleagues reported similar findings for a group of 302 patients with migraine headaches where the comparison groups were acupuncture, sham acupuncture, and waiting-list control. (52)

Other Conditions

Finally, a number of additional clinical areas are being studied and reported for use of acupuncture. These clinical issues are varied and include treatment of functional gastrointestinal disorders, improving the pregnancy rate for women undergoing embryo transfer (IVF), treatment of allergic rhinitis, vascular dementia, depression, and overactive bladder. More scientific data and information about outcomes are needed before coverage can be considered for these various indications.

Medicare Coverage Policy Position

The Centers for Medicare and Medicaid Services (CMS) currently do not cover acupuncture under any condition and issued a national noncoverage determination for acupuncture in May 1980. In April 2004, CMS issued noncoverage decisions for acupuncture for pain relief in fibromyalgia and osteoarthritis. (41, 42) Citing study design flaws, CMS concluded there is no convincing evidence that acupuncture is useful in improving health outcomes. Therefore, CMS affirmed acupuncture is not reasonable and necessary for pain relief in fibromyalgia or osteoarthritis.

References:

1. 1996 TEC Assessments, Tab 22.
2. National Institutes of Health . Acupuncture. NIH Consensus Statement 1997; 15(5):1-34.
3. Vickers AJ. Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. J R Soc Med 1996; 89(6):303-11.
4. Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999; 88(6):1362-9.
5. Sung YF, Kutner, MH, Cerine FC et al.Comparison of the effects of acupuncture and codeine on postoperative dental pain. Anesth Analg 1977; 56(4):473-8.
6. Lao L, Bergman S, Langenberg P et al.Efficacy of Chinese acupuncture on postoperative oral surgery pain. Oral Surg Med Oral Pathol 1995; 79(4):423-8.
7. Lao L, Bergman S, Hamilton GR et al.Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial. Arch Otolaryngol Head Neck Surg 1999; 125(5):567-72.
8. van Tulder MW, Cherkin DC, Berman B et al.Acupuncture for low back pain (Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software.
9. Ernst E, White AR. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Arch Intern Med 1998; 158(20):2235-41.
10. Carlsson CP, Sjolund BH. Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up. Clin J Pain 2001; 17(4):296-305.
11. Leibing E, Leonhardt U, Koster G et al.Acupuncture treatment of chronic low-back pain -- a randomized, blinded, placebo-controlled trial with 9-month follow-up. Pain 2002; 96(1-2):189-96.
12. Melchart D, Linde K, Fischer P et al.Acupuncture for idiopathic headache(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software.(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software
13. Green S, Buchbinder R, Barnsley L et al.Acupuncture for lateral elbow pain(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software.(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software
14. Fink M, Wolkenstein E, Karst M et al.Acupuncture in chronic epicondylitis: a randomized controlled trial. Rheumatology (Oxford) 2002; 41(2):205-9.
15. Casimiro L, Brosseau L, Milne S et al.Acupuncture and electroacupuncture for the treatment of RA(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software.(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software
16. ter Riet G, Kleijnen J, Knipschild P.Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol 1990; 43(11):1191-9.
17. Patel M, Gutzwiller F, Paccaud F et al.A meta-analysis of acupuncture for chronic pain. Int J Epidemiol 1989; 18(4):900-6.
18. Ezzo J, Berman B, Hadhazy VA et al. Is acupuncture effective for the treatment of chronic pain? A systematic review. Pain 2000; 86(3):217-25.
19. Ezzo J, Hadhazy V, Birch S et al. Acupuncture for osteoarthritis of the knee: a systematic review. Arthritis Rheum 2001; 44(4):819-25.
20. Berman BM, Ezzo J, Hadhazy V et al.Is acupuncture effective in the treatment of fibromyalgia? J Fam Pract 1999; 48(3):213-8.
21. Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001; 82(7):986-92.
22. SmithCA, Crowther CA. Acupuncture for induction of labour (Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software.
23. Linde K, Jobst K, Panton J.Acupuncture for chronic asthma(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software.(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software
24. Gruber W, Eber E, Malle-Scheid D et al.Laser acupuncture in children and adolescents with exercise induced asthma. Thorax 2002; 57(3):222-5.
25. Shapira MY, Berkman N, Ben-David G et al.Short-term acupuncture therapy is of no benefit in patients with moderate persistent asthma. Chest 2002; 121(5):1396-400.
26. WhiteAR, Rampes H, Ernst E. Acupuncture for smoking cessation(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software.(Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software
27. Bullock ML, Umen AJ, Culliton PD et al.Acupuncture treatment of alcoholic recidivism: a pilot study. Alcohol Clin Exp Res 1987; 11(3):292-5.
28. Bullock ML, Culliton PD, Olander RT. Controlled trial of acupuncture for severe recidivist alcoholism. Lancet 1989; 1(8652):1435-9.
29. Konefal J, Duncan R, Clemence C.Comparison of three levels of auricular acupuncture in an outpatient substance abuse treatment program. Altern Med J 1995; 2:8-17.
30. Margolin A, Avants SK, Chang P et al. Acupuncture for the treatment of cocaine dependence in methadone-maintained patients. Am J Addict 1993; 2:194-201.
31. Bullock ML, Kiresuk TJ, Pheley AM et al.Auricular acupuncture in the treatment of cocaine abuse. A study of efficacy and dosing. J Subst Abuse Treat 1999; 16(1):31-8.
32. Naeser MA. Acupuncture in the treatment of paralysis due to central nervous system damage. J Altern Complement Med 1996; 2(1):211-48.
33. Johansson BB, Haker E, von Arbin M et al.Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial. Stroke 2001; 32(3):707-13.
34. Berman BM, Lao L, Langenberg P et al.Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee. Ann Intern Med 2004;141(12):901-10.
35. Vas J, Mendez C, Perea-Milla P et al.Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ 2004; 329(7476):1216-19.
36. Vickers AJ, Rees RW, Zollman C et al.Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial. BMJ 2004; 328(7442):744.
37. Kvorning N, Holmberg C, Grennert L et al.Acupuncture relieves pelvic and low-back pain in late pregnancy. Acta Obstet Gynecol Scand 2004; 83(3):246-50.
38. White P, Lewith G, Prescott P et al. Acupuncture versus placebo for the treatment of chronic mechanical neck pain. Ann Intern Med 2004; 141(12):911-9.
39. Streitberger K, Diefenbacher M, Bauer A et al. Acupuncture compared to placebo-acupuncture for postoperative nausea and vomiting prophylaxis: a randomised placebo-controlled patient and observer blind trial. Anesthesia 2004;59(2):142-9.
40. Stener-Victorin E, Kruse-Smidje C, Jung K.Comparison between electro-acupuncture and hydrotherapy, both in combination with patient education and patient education alone, on the symptomatic treatment of osteoarthritis of the hip. Clin J Pain 2004; 20(3):179-85.
41. MedicarePolicy.AcupunctureforFibromyalgia.http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=30.3.1&ncd_version=1
42. MedicarePolicy.AcupunctureforOsteoarthritis.http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=30.3.2&ncd_version=1
43. Trinh KV, Graham N, Gross AR et al. Acupuncture for neck disorders. Cochrane Database Syst Rev 2006; (3):CD004870.
44. Witt CM, Jena S, Brinkhaus B et al. Acupuncture for patients with chronic neck pain. Pain 2006; 125(1-2):98-106.
45. Scharf HP, Mansmann U, Streitberger K et al. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med 2006; 145(1):12-20.
46. Witt C, Brinkhaus B, Jena S et al. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet 2005; 366(9480):136-43.
47. Brinkhaus B, Witt CM, Jena S et al. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med 2006; 166(4):450-7.
48. Thomas KJ, MacPherson H, Ratcliffe J et al. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technol Assess 2005; 9(32):1-109.
49. Assefi NP, Sherman KJ, Jacobsen C et al. A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Ann Intern Med 2005; 143(1):10-9.
50. Martin DP, Sletten CD, Williams BA et al. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clin Proc 2006; 81(6):749-57.
51. Melchart D, Streng A, Hoppe A et al. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ 2005; 331(7513):376-82.
52. Linde K, Streng A, Jurgens S et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA 2005; 293(17):2118-25.
53. MedicarePolicy.AcupunctureforFibromyalgia.http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=30.3.1&ncd_version=1 
54. MedicarePolicy.AcupunctureforOsteoarthritis.http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=30.3.2&ncd_version=1 

Codes	Number	Description
CPT	97780	Acupuncture, one or more needles; without electrical simulation (deleted effective 12/31/04)
	97781	Acupuncture, one or more needles; with electrical stimulation (deleted effective 12/31/04)
	97810	Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
	97811	Each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needle(s) (List separately in addition to code for primary procedure)
	97813	Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
	97814	Each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needle(s) (List separately in addition to code for primary procedure)
ICD-9 Procedure	99.91	Acupuncture for anesthesia
	99.92	Other acupuncture
ICD-9 Diagnosis		Investigational for all codes
HCPCS	A4215	Needles only, sterile, any size
Type of Service	Surgery
Place of Service	Inpatient   Outpatient   Physician’s Office

Acupuncture

Date	Action	Reason
11/01/96	Add policy to Surgery section	New policy
12/18/02	Replace policy	Policy revised; new medically necessary indication for nausea associated with surgery, chemotherapy, or pregnancy. Other indications for acupuncture remain investigational. Rationale expanded and references added
12/17/03	Replace policy	Policy reviewed by consensus without literature review; no changes in policy
07/15/04	Replace policy	Medicare noncoverage decision for fibromyalgia and ostoeoarthritis added; no change in policy statement
11/9/04	Replace policy	Coding updated. 2005 CPT coding changes added
06/27/05	Replace policy	Policy updated with literature review; no changes in policy statement; references 34 - 40 added
10/10/06	Replace policy	Policy updated with literature review; no changes in policy statement; reference numbers 41-52 added.