Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

INDEX:



Effective Date: 05/21/2004	Title: Acupuncture
Revision Date: 08/23/2011	Document: BI034:00
CPT Code(s): 97810-97811, 97813-97814
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Acupuncture and acupressure are not covered benefits under policies issued by QualChoice/QCA. The scientific evidence regarding the effectiveness of acupuncture is conflicting and generally insufficient to establish its validity.
Medical Statement
Acupuncture is not a generally accepted procedure for treatment of injury or disease and is not as yet accepted by mainstream practitioners. Acupuncture is considered as Alternative or Complimentary Medicine and should be denied for coverage as benefit exclusion. Codes Used In This BI: 97810 Acupuncture w/o stimul 15 min 97811 Acupuncture w/o stimul addl 15m 97813 Acupuncture w/stimul 15 min 97814 Acupuncture w/stimul addl 15m
Limits
Not a covered benefit.
Reference
HCFA Coverage Issues Manual, Medical Procedures, #35-8 Acupuncture, page 5. http://www.hcfa.gov/pubforms/06-cim/ci35.htm Hayes Manual Hayes: Acupuncture and Acupressure for the Treatment of Nausea and Vomiting; Nov 2001 Hayes: Acupuncture for Addictive Behavior; Nov 2001 Hayes: Acupuncture for the Treatment of Pain; Aug 2001 Hayes Alert, Vol VII, Number 4 – April 2004: Acupuncture for Chronic Headache February 2003 National Coverage Determination brief: Medicare is not covering acupuncture for fibromyalgia, nausea after chemo, post operative pain, or osteoarthritis. NIH is assessing the use for surgical anesthesia and chronic pain management, but Medicare is not paying for acupuncture until these studies are complete and efficacy has been established.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.