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National Coverage Determination (NCD)

Acupuncture for Fibromyalgia

30.3.1

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Tracking Information

Publication Number
100-3
Manual Section Number
30.3.1
Manual Section Title
Acupuncture for Fibromyalgia
Version Number
1
Effective Date of this Version
04/16/2004
Ending Effective Date of this Version
01/21/2020
Implementation Date
04/16/2004
Implementation QR Modifier Date

Description Information

Benefit Category
Incident to a physician's professional Service
Inpatient Hospital Services
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

General

Although acupuncture has been used for thousands of years in China and for decades in parts of Europe, it is still a relatively new agent of unknown use and efficacy in the United States. Even in those areas of the world where it has been widely used, its mechanism is not known.  Three units of the National Institutes of Health, the National Institute of General Medical Sciences, National Institute of Neurological Diseases and Stroke, and Fogarty International Center were designated to assess and identify specific opportunities and needs for research attending the use of acupuncture for surgical anesthesia and relief of chronic pain. Following thorough review, and pending completion of the scientific assessment and efficacy of the technique, CMS initially issued a national noncoverage determination for acupuncture in May 1980.
Indications and Limitations of Coverage

Nationally Covered Indications

Not applicable.

Nationally Noncovered Indications

After careful reconsideration of its initial noncoverage determination for acupuncture, CMS concludes that there is no convincing evidence for the use of acupuncture for pain relief in patients with fibromyalgia. Study design flaws presently prohibit assessing acupuncture’s utility for improving health outcomes. Accordingly, CMS determines that acupuncture is not considered reasonable and necessary for the treatment of fibromyalgia within the meaning of §1862(a)(1) of the Social Security Act, and the national noncoverage determination for acupuncture continues.

(This NCD last reviewed April 2004.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
11
Coverage Transmittal Link
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R11NCD.pdf
Revision History

04/2004 - Noncoverage for acupuncture continued. Effective and implementation dates 04/16/2004. (TN 11) (CR 3250)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Acupuncture for Fibromyalgia 2 01/21/2020 - N/A View
Acupuncture for Fibromyalgia 1 04/16/2004 - 01/21/2020 You are here
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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