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Acupuncture
Number: 0135
Policy History
Policy
Note: Most Aetna plans limit coverage of acupuncture to when it Last Review 03/29/2017
is used in a lieu of other anesthesia for a surgical or dental Effec ve: 07/19/1996
procedure covered under the health benefits plan, and the health Next Review: 01/25/2018
care provider administering it is a legally qualified physician
prac cing within the scope of his/her license. Some other plans Review History
may extend coverage of acupuncture for medically necessary
indica ons, but only when administered by a health care provider Defini ons
who is a legally qualified physician prac cing within the scope of
his/her license. Please check benefit plan descrip ons for details.
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Background
Acupuncture as a therapeu c interven on is widely prac ced in
the United States. The general theory of acupuncture is based on
the premise that there are pa erns of energy flow (Qi) through
the body that are essen al for health. Disrup ons of this flow
are believed to be responsible for disease. Acupuncture may
correct imbalances of flow at iden fiable points close to the skin.
Findings from basic research have begun to elucidate the
mechanisms of ac on of acupuncture, including the release of
opioids and other pep des in the central nervous system and the
periphery and changes in neuroendocrine func on.
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reducing the need for ECV, and decreasing the use of oxytocin;
however there is a need for well-designed randomised controlled
trials to evaluate moxibus on for breech presenta on which
report on clinically relevant outcomes as well as the safety of the
interven on.
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was related to MSNA burst frequency (Rs = 0.58, p < 0.005) in the
EA group. No correla on was found for body mass index and
MSNA in the exercise group. There were no differences between
the groups in hemodynamic, endocrine, and metabolic variables.
For the first me, these researchers showed that low-frequency
EA and physical exercise lowers high sympathe c nerve ac vity in
women with PCOS. Thus, treatment with low-frequency EA or
physical exercise with the aim to reduce MSNA may be of
importance for women with PCOS.
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measured using the ocular surface disease index (OSDI), the VAS
of ocular discomfort, the tear film break-up me (TFBUT) and the
Schimer I test with anesthesia. In addi on, adverse events were
recorded. There were no sta s cally significant differences
between results on the OSDI, VAS, TFBUT or Schimer I tests from
baseline between the verum and sham acupuncture groups.
However, results from the within-group analysis showed that the
OSDI and VAS in both groups and the TFBUT in the verum
acupuncture group were significantly improved a er 3 weeks of
treatment. No adverse events were reported during this trial.
The authors concluded that both types of acupuncture improved
signs and symptoms in dry-eye pa ents a er a 4-week
treatment. However, verum acupuncture did not result in be er
outcomes than sham acupuncture.
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Cao and colleagues (2013) evaluated the safety and effec veness
of acupuncture for pa ents with vascular mild cogni ve
impairment (VMCI). A total of 7 electronic databases were
searched for RCTs that inves gated the effects of acupuncture
compared with no treatment, placebo or conven onal therapies
on cogni ve func on or other clinical outcomes in pa ents with
VMCI. The quality of the trials selected was evaluated according
to the “risk of bias” assessment provided by the Cochrane
Handbook for Systema c Reviews of Interven ons. RevMan V.5.1
so ware was employed for data analysis. A total of 12 trials with
691 par cipants were included. The methodological quality of all
included trials was unclear and/or they had a high-risk of bias.
Meta-analysis showed acupuncture in conjunc on with other
therapies could significantly improve Mini-Mental State
Examina on scores (mean difference 1.99, 95 % CI: 1.09 to 2.88,
random model, p < 0.0001, 6 trials). No included trials
men oned any adverse events of the treatment. The authors
concluded that the current clinical evidence is not of sufficient
quality for wider applica on of acupuncture to be recommended
for the treatment of VMCI; they stated that further large,
rigorously designed trials are warranted.
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Zhu and colleagues (2013) examined the safety and effec veness
of acupuncture for pain in endometriosis. These inves gators
searched the Cochrane Menstrual Disorders and Subfer lity
Group (MSDG) Specialized Register of controlled trials, Cochrane
Central Register of Controlled Trials (CENTRAL) (The Cochrane
Library), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, CNKI and
TCMDS (from incep on to 2010) and reference lists of retrieved
ar cles. Randomized single or double-blind controlled trials
enrolling women of reproduc ve age with a laparoscopically
confirmed diagnosis of endometriosis and comparing
acupuncture (body, scalp or auricular) to either placebo or sham,
no treatment, conven onal therapies or Chinese herbal medicine
were selected for analysis. Three authors independently
assessed risk of bias and extracted data; they contacted study
authors for addi onal informa on. Meta-analyses were not
performed as only 1 study was included. The primary outcome
measure was decrease in pain from endometriosis. Secondary
outcome measures included improvement in quality of life
scores, pregnancy rate, adverse effects and rate of endometriosis
recurrence. A total of 24 studies were iden fied that involved
acupuncture for endometriosis; however only 1 trial, enrolling 67
par cipants, met all the inclusion criteria. The single included
trial defined pain scores and cure rates according to the
Guideline for Clinical Research on New Chinese Medicine.
Dysmenorrhea scores were lower in the acupuncture group
(mean difference -4.81 points, 95 % CI: -6.25 to -3.37, p <
0.00001) using the 15-point Guideline for Clinical Research on
New Chinese Medicine for Treatment of Pelvic Endometriosis
scale. The total effec ve rate (“cured”, “significantly effec ve” or
“effec ve”) for auricular acupuncture and Chinese herbal
medicine was 91.9 % and 60 %, respec vely (risk ra o 3.04, 95 %
CI: 1.65 to 5.62, p = 0.0004). The improvement rate did not differ
significantly between auricular acupuncture and Chinese herbal
medicine for cases of mild-to-moderate dysmenorrhea, whereas
auricular acupuncture did significantly reduce pain in cases of
severe dysmenorrhea. Data were not available for secondary
outcomes measures. The authors concluded that the evidence to
support the effec veness of acupuncture for pain in
endometriosis is limited, based on the results of only a single
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but due to flaws in study designs (par cularly small popula ons,
uncertain alloca on concealment and substan al loss to follow-
up) and clinical differences between trials, data from trials could
not be combined in a meta-analysis. One RCT found that needle
acupuncture results in relief of pain for significantly longer than
placebo (weighted mean difference [WMD] = 18.8 hours, 95 % CI:
10.1 to 27.5) and is more likely to result in a 50 % or greater
reduc on in pain a er 1 treatment (RR 0.33, 95 % CI: 0.16 to
0.69) (Molsberger 1994). A second RCT demonstrated needle
acupuncture to be more likely to result in overall par cipant
reported improvement than placebo in the short term (RR = 0.09
95 % CI: 0.01 to 0.64) (Haker 1990a). No significant differences
were found in the longer term (a er 3 or 12 months). A RCT of
laser acupuncture versus placebo demonstrated no differences
between laser acupuncture and placebo with respect to overall
benefit (Haker 1990b). A 4th RCT included trial published in
Chinese demonstrated no difference between vitamin B12
injec on plus acupuncture, and vitamin B12 injec on alone
(Wang 1997). The authors concluded that there is insufficient
evidence to either support or refute the use of acupuncture
(either needle or laser) in the treatment of lateral elbow pain.
This review has demonstrated needle acupuncture to be of
short-term benefit with respect to pain, but this finding is based
on the results of 2 small trials, the results of which were not able
to be combined in meta-analysis. No benefit las ng more than
24 hours following treatment has been demonstrated. No trial
assessed or commented on poten al adverse effect. They stated
that further trials, u lizing appropriate methods and adequate
sample sizes, are needed before conclusions can be drawn
regarding the effect of acupuncture on tennis elbow.
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Heart Failure:
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Plantar Fascii s:
Post-Opera ve Ileus:
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Lee and Lim (2016) evaluated the evidence on the effec veness
of acupuncture in relieving post-stroke shoulder pain. A total of 7
databases were searched without language restric ons. All RCTs
that evaluated the effects of acupuncture for post-stroke
shoulder pain compared with controls were included.
Assessments were performed primarily with the VAS, Fugl-Meyer
Assessment (FMA), and effec ve rates. In all, 188 poten ally
relevant ar cles were iden fied; 12 were RCTs that met inclusion
criteria. Meta-analysis showed that acupuncture combined with
rehabilita on treatment appeared to be more effec ve than
rehabilita on treatment alone for post-stroke shoulder pain, as
assessed by VAS (WMD, 1.87; 95 % CI: 1.20 to 2.54; p < 0.001);
FMA (WMD, 8.70; 95 % CI: 6.58 to 10.82; p < 0.001); and effec ve
rate (RR, 1.31; 95 % CI: 1.18 to 1.47; p < 0.001). The authors
concluded that although there is some evidence for an effect of
acupuncture on post-stroke shoulder pain, the results are
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Appendix
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goals of acupuncture.
G43.001 - Migraine
G43.919
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ICD-10 codes not covered for indica ons listed in the CPB (not all-
inclusive) :
B26.0 - Mumps
B26.9
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G47.00 - Insomnia
G47.09
H40.001 - Glaucoma
H40.9
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H52.10 - Myopia
H52.13
H93.11 - Tinnitus
H93.19
K59.00 - Cons pa on
K59.09
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N80.0 - Endometriosis
N80.9
N94.4 - Dysmenorrhea
N94.6
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R10.83 Colic
R63.2 Polyphagia
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297.
142. Roberts J, Huissoon A, Dretzke J, et al. A systema c review
of the clinical effec veness of acupuncture for allergic
rhini s. BMC Complement Altern Med. 2008;8:13.
143. Xie Y, Wang L, He J, Wu T. Acupuncture for dysphagia in
acute stroke. Cochrane Database Syst Rev. 2008;
(3):CD006076.
144. Facco E, Liguori A, Pe F, et al. Tradi onal acupuncture in
migraine: A controlled, randomized study. Headache.
2008;48(3):398-407.
145. Smith CA, Crowther CA, Collins CT, Coyle ME. Acupuncture
to induce labor: A randomized controlled trial. Obstet
Gynecol. 2008;112(5):1067-1074.
146. Cheong YC, Hung Yu Ng E, Ledger WL. Acupuncture and
assisted concep on. Cochrane Database Syst Rev. 2008;
(4):CD006920.
147. El-Toukhy T, Sunkara SK, Khairy M, et al. A systema c
review and meta-analysis of acupuncture in in vitro
fer lisa on. BJOG. 2008;115(10):1203-1213.
148. Ng EH, So WS, Gao J, et al. The role of acupuncture in the
management of subfer lity. Fer l Steril. 2008;90(1):1-13.
149. Lam YC, Kum WF, Durairajan SS, et al. Efficacy and safety of
acupuncture for idiopathic Parkinson's disease: A
systema c review. J Altern Complement Med.
2008;14(6):663-671.
150. Ben-Aharon I, Ga er-Gvili A, Paul M, et al. Interven ons for
allevia ng cancer-related dyspnea: A systema c review. J
Clin Oncol. 2008;26(14):2396-2404.
151. Bausewein C, Booth S, Gysels M, Higginson IJ. Non-
pharmacological interven ons for breathlessness in
advanced stages of malignant and non-malignant diseases.
Cochrane Database Syst Rev. 2008;(2):CD005623.
152. Lee H, Kim SY, Park J, et al. Acupuncture for lowering blood
pressure: Systema c review and meta-analysis. Am J
Hypertens. 2009;22(1):122-128.
153. Thomas LH, Cross S, Barre J, et al. Treatment of urinary
incon nence a er stroke in adults. Cochrane Database Syst
Rev. 2008;(1):CD004462.
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulle ns are developed by Aetna to assist in administering
plan benefits and cons tute neither offers of coverage nor medical advice. This Clinical Policy Bulle n contains only a
par al, general descrip on of plan or program benefits and does not cons tute a contract. Aetna does not provide
health care services and, therefore, cannot guarantee any results or outcomes. Par cipa ng providers are
independent contractors in private prac ce and are neither employees nor agents of Aetna or its affiliates. Trea ng
providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulle n may be
updated and therefore is subject to change.
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