Acupuncture Is Coming Soon to an MSA Near You: CMS Issues Decision to Cover Acupuncture for Medicare Beneficiaries

CMS, Medicare, Medicare Set-Aside Blog, MSP News, Opioids on January 22, 2020
Posted by Jean S. Goldstein, JD, CMSP

Yesterday, CMS issued a decision to cover acupuncture for Medicare patients with chronic low back pain (cLBP) to some extent.  You may recall that CMS previously issued a proposed decision to cover acupuncture, as we discussed here on our blog.  CMS’ final coverage decision memo can be found here, and indicates that acupuncture for chronic low back pain (cLBP) will be covered for Medicare beneficiaries.  CLBP is defined as pain which is:

  • 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

For those that experience cLBP as defined above, up to 12 visits in 90 days will be Medicare-covered.  An additional eight sessions will be covered for those patients demonstrating an improvement, and no more than 20 acupuncture treatments may be administered annually. The decision also states that treatment must be discontinued if the patient is not improving or is regressing.

Since acupuncture is now a Medicare-covered expense for cLBP, Medicare Set-Asides (MSAs) will be impacted.  However, acupuncture is relatively inexpensive, with costs very similar to physical therapy, and the results of the studies have proven that acupuncture is a very viable noninvasive chronic pain treatment option.  Of note, CMS conducted a National Coverage Study to determine the viability of acupuncture as a treatment option, and did not consider acute low back pain or pain associated with pregnancy or surgery.  The decision regarding coverage takes into account an assessment of benefits and harms and the opioid public health crisis.  After reviewing the evidence from the study, the relative safety of acupuncture, and the grave consequences of the opioid crisis in the United States, CMS determined that there is sufficient rationale to provide this nonpharmacologic treatment to appropriate beneficiaries with cLBP.

Stay tuned for a further analysis once we begin to see acupuncture readily applied in claims involving cLBP.