Acupuncture and Medicare – two words that I never thought would be together in the same sentence. However, now that they are connected, it’s time to learn about acupuncture and Medicare, especially if you suffer from chronic low back pain.
The practice of acupuncture most likely originated in China over 2,500 years ago. Traditional Chinese medicine believes inserting thin needles through the skin to stimulate specific points on the body rebalances the flow of energy.
In the U.S., this alternative treatment struggled to gain acceptance. Research findings were inconclusive, and it was viewed as creating a placebo effect more than medical relief.
That attitude started to change in 1997. The National Institutes of Health (NIH) reported positive evidence for acupuncture’s effectiveness. Research studies demonstrated acupuncture’s value in treating nausea (from various causes, including chemotherapy), dental pain, headache, and back pain.
Even though more than 10 million acupuncture treatments are administered annually in the United States alone, insurance coverage has been described as inconsistent. One survey of 45 commercial, Medicaid, and Medicare Advantage plans found that only one-third covered acupuncture, suggesting most patients pay for acupuncture treatments entirely out-of-pocket.
But Medicare would not budge. The Centers for Medicare and Medicaid Services (CMS) did not consider acupuncture to be reasonable and necessary and determined there was no convincing evidence that it relieved pain.
The Opioid Crisis
Then, that all changed because of one issue, opioids. Chronic low back pain affects most adults for which opioid prescriptions became a common treatment. However, systematic reviews found scant evidence of opioids’ effectiveness in treating low back pain. As use of opioids increased so did drug misuse, complications and fatal overdoses.
In the Medicare population in 2016, the Office of the Inspector General reported that one-third of beneficiaries received at least one opioid prescription through Part D prescription drug coverage. One in 10 received opioids on a regular basis, with 3.6 million beneficiaries receiving opioids for six or more months.
The studies raised significant concerns. In January 2020, CMS announced that Medicare would cover acupuncture for chronic low back pain as an alternative to opioid medications.
Here’s What You Need to Know
- Medicare will cover all types of acupuncture, including dry needling, for treatment of chronic low back pain.
- Medicare does not cover acupuncture for any other condition.
- To qualify for coverage of acupuncture, a beneficiary must have chronic low back pain of 12 weeks duration or longer with no systemic cause and the pain is not associated with surgery.
- Medicare will cover up to 12 sessions in 90 days with an additional eight sessions for those who demonstrate improvement.
- Treatments must be administered by a doctor or a physician’s assistant, nurse practitioner, or healthcare professional with a master’s or doctorate level training in acupuncture and a state license to practice acupuncture.
If you have Part A and Part B, along with a Medicare supplement insurance plan (Medigap policy):
- You will need to see a provider who accepts Medicare assignment and is able to submit claims to Medicare.
- If you’ve been receiving treatments from a local acupuncturist, confirm that he or she meets Medicare criteria.
- The Part B deductible and 20% coinsurance will apply.
If you elected Medicare Advantage:
- You will have to find a provider in-network. Miles Inhofer, acupuncturist with Aurora Health Care in Milwaukee, advised talking with a plan representative. The healthcare facility where you see all your in-network providers may not be the one where you’ll receive acupuncture. This program is relatively new in Medicare terms, and providers are figuring out their systems and protocols.
- The Medicare Advantage plan can require referral and prior authorization.
- The plan’s cost sharing (deductible and copayment) may apply.
- Medicare Advantage plans can opt to cover acupuncture for other medical conditions. Check the plan’s Evidence of Coverage for more details.
An Example
In many of my posts, I share a real-life story. This one is mine. In simplest terms, my back is a mess, primarily the result of a genetic inflammatory disease and a car crash. For almost 30 years, a non-steroidal anti-inflammatory drug (NSAID) controlled my pain. But as with many medications, it was taking a toll on some vital organs and I had to stop the drug. Since then, I have tried a variety of remedies.
Last fall, acupuncture popped into my mind, so I decided to give it a try. My treatments have been similar to what websites tell you. I lay on a table and the acupuncturist inserts needles in various spots, including my back, hands, and feet. Generally, I only feel pressure but sometimes my hands are a bit more sensitive. (I will speak up if I feel pain.) I stay in that position, in a darkened room, for about 30 minutes. Treatments started weekly and now are every three weeks.
I have combined acupuncture with other activities to control the pain, including walking, daily back exercises, and regular water aerobics. At this time, my back pain is under control. How long will that last? I found some studies that report acupuncture provides short-term relief and one reporting long-term relief (12 months). Given this is all new, I will take it one day at a time.
In the beginning, opioids were seen as a non-addicting solution for chronic back pain. But, now that we know better, Medicare’s decision to cover acupuncture gives many beneficiaries a new option. Perhaps Medicare will realize that the ancient technique has a place in the modern world.