Acupuncture Services
Provider Type
- Physicians and Practitioners
- Ancillary
- Participating Physician Groups (PPG)
The following information applies to HSP, HMO, Ambetter HMO and Ambetter PPO members.
Acupuncture services for treatment or diagnosis of musculoskeletal and related disorders, nausea, and pain are a covered benefit for some members. Refer to the member's Evidence of Coverage (EOC) to confirm if the member is eligible for acupuncture services.
Acupuncture services are administered by the American Specialty Health Plans, Inc. (ASH Plans) network of participating acupuncturists without a referral from the member's primary care physician (PCP) as stated in the EOC.
Refer the member to ASH Plans or the Member Services Department for more information about acupuncture services.
Coverage Criteria
Acupuncture services for treatment or diagnosis of musculoskeletal and related disorders, nausea, and pain are a covered benefit, subject to medical benefits exclusions, limitations and authorization protocols listed in the EOC. Subsequent visits are authorized by ASH when medically necessary as stated in the EOC.
Additional services in subsequent visits may include:
- Adjunctive therapies or modalities such as acupressure, moxibustion or breathing techniques are covered only when provided during the same course of treatment and in support of acupuncture services.
The following information applies to PPO members.
Acupuncture services for treatment or diagnosis of musculoskeletal and related disorders, nausea, and pain are a covered benefit for some members. Refer to the member's EOC to confirm if the member is eligible for acupuncture services.
Coverage Criteria
Acupuncture services for treatment or diagnosis of musculoskeletal and related disorders, nausea, and pain are a covered benefit, subject to medical benefits exclusions, limitations and authorization protocols listed in the EOC. Subsequent visits are authorized when medically necessary as stated in the EOC.
Additional services in subsequent visits may include:
- Adjunctive therapies or modalities such as acupressure, moxibustion or breathing techniques are covered only when provided during the same course of treatment and in support of acupuncture services.
Exclusions and Limitations
Services, laboratory tests, X-rays and other treatment not approved by American Specialty Health Plans, Inc. (ASH Plans) and documented as medically/clinically necessary as appropriate or classified as experimental, and/or being in the research stage, as determined in accordance with professionally recognized standards of practice are not covered. If a member has a life-threatening or seriously debilitating condition and ASH Plans denies coverage based on the determination that the therapy is experimental, they may be able to request an independent medical review of ASH Plans’ determination. The member can contact ASH Plans for more information.
Additional exclusions and limitations include, but are not limited to, the following:
- Auxiliary aids - Auxiliary aids and services are not covered. This includes but is not limited to interpreters, transcription services, written materials, telecommunications devices, telephone handset amplifiers, television decoders and telephones compatible with hearing aids.
- Diagnostic radiology - No diagnostic radiology (including x-rays, magnetic resonance imaging or MRI) is covered.
- Drugs - Prescription drugs and over-the-counter drugs are not covered.
- Durable medical equipment - Durable medical equipment is not covered.
- Educational programs - Educational programs, nonmedical self-care, self-help training and related diagnostic testing are not covered.
- Experimental or investigational acupuncture services - Acupuncture care that is (a) investigatory; or (b) an unproven acupuncture service that does not meet generally accepted and professionally recognized standards of practice in the acupuncture provider community is not covered. ASH Plans will determine what will be considered experimental or investigational.
- Hospital charges - Charges for hospital confinement and related services are not covered.
- Anesthesia - Charges for anesthesia are not covered.
- Hypnotherapy - Hypnotherapy, sleep therapy, behavior training and weight programs are not covered.
- Noncontracted providers - Services or treatment rendered by acupuncturists who do not contract with ASH Plans are not covered, except with regard to emergency acupuncture services or upon referral by ASH Plans.
- Acupuncture services not listed under acupuncture services in the EOC - Only acupuncture services that are listed under “Acupuncture Services” in the EOC are covered. Unlisted services, which include, without limitation, services to treat asthma and services to treat any addiction, including treatment for smoking cessation, are not covered.
- Out-of-state services - Services provided by an acupuncturist practicing outside California are not covered, except with regard to emergency acupuncture services.
- Thermography - The diagnostic measuring and recording of body heat variations (thermography) are not covered.
- Transportation costs - Transportation costs are not covered, including local ambulance charges.
- X-ray and laboratory tests - X-ray and laboratory tests are not covered.
- Medically/clinically unnecessary services - Only Acupuncture Services that are necessary, appropriate, safe, effective and that are rendered in accordance with professionally recognized, valid, evidence-based standards of practice are covered.
- Services not within license - Only services that are within the scope of licensure of a licensed acupuncturist in California are covered. Other services, including, without limitation, ear coning and Tui Na are not covered. Ear coning, also sometimes called “ear candling,” involves the insertion of one end of a long, flammable cone (“ear cone”) into the ear canal. The other end is ignited and allowed to burn for several minutes. The ear cone is designed to cause smoke from the burning cone to enter the ear canal to cause the removal of earwax and other materials. Tui Na, also sometimes called “Oriental Bodywork” or “Chinese Bodywork Therapy,” utilizes the traditional Chinese medical theory of Qi but is taught as a separate but equal field of study in the major traditional Chinese medical colleges and does not constitute acupuncture.
- Vitamins - Vitamins, minerals, nutritional supplements or other similar products are not covered.