Medicare Covers, but Also Does Not Cover, Acupuncture

 

 

Executive summary: Medicare sort of covers acupuncture for low back pain, but coverage is so limited as to be meaningless for most patients unless they have certain Medicare Advantage plans.

Every year, the fine folk at Medicare send out a thick book about coverage to all beneficiaries. The 2021 book contained extremely misleading wording about coverage for acupuncture. A person who didn’t know better would come away with the impression that they could get at least 12 covered sessions of acupuncture for chronic low back pain.

Except that’s not really the case.

Quite understandably, lots of people have called acupuncture offices trying to set up treatment and expecting to pay only small copays. Sometimes, when the office staff explain that we can’t make that happen, they get really upset. Sometimes they call Medicare, get further wrong information, and come back even more upset. A colleague in another state reported recently that a patient became loud and violent in her waiting room, abusing the staff and insisting that the acupuncturist had fraudulently taken his money when she treated him.

I think we can all agree that having violent tantrums in health care offices is generally not OK. It’s also not OK for a major government agency to give people totally wrong information, and I don’t blame anyone for being annoyed at that.

This mistake is likely not intentional, though. The regulation is written in such a mystifyingly nonsensical way that the people promulgating the information may have honestly failed to understand it. I’m willing to give them the benefit of the doubt to a certain extent.

Here’s what’s really going on:

In early 2020, a decision was made by the Powers That Be at Centers for Medicare & Medicaid Services (CMS) to add Medicare coverage for acupuncture for one well-studied condition, chronic low back pain. I don’t know precisely what the tipping point was that made this happen, but over many years there had been agitation from our profession and popular demand from patients, numerous positive studies, and recommendations from other government entities such as NIH to promote the use of non-opioid treatments for pain. Whatever it was, Medicare finally budged, and it even specified that those wielding the needles had to be licensed to do acupuncture. That is, such providers as physical therapists doing dry needling would not be included.

Here is the CMS decision memo describing the new coverage and the reasons it was chosen:

https://drive.google.com/file/d/1hoSyfCBMSXrjbIQRNA29S1NQmfFuLEzP/view

I must say that it’s a carefully and clearly written document. Some of the conclusions in it are astonishing, however, such as the contention that there is no convincing evidence for the use of acupuncture for osteoarthritis.

The trouble is that acupuncturists are not Medicare providers. We are essentially invisible to the Medicare system. There is no pathway for us to sign up to be providers, so we cannot bill for our services. In order to do this supposedly covered low back pain treatment, we must be supervised by a Medicare provider such as an MD or NP, with our treatment being “incident to” their care, and we must have billing done under that person’s name and get reimbursed through them.

This means that only acupuncturists who work in hospitals or mainstream medical clinics have any chance of this actually getting coverage to happen. It means, therefore, that there are hardly any acupuncturists who can provide treatment under Medicare. And I hear it’s been very difficult for even those few to ever collect payment.

This is an insane and completely unsustainable situation, but while we’ve been focused on the pandemic, it has gone on for nearly two years without any improvement that I know of. (And Medicare members who need help for something other than low back pain are out in the cold entirely.) Acupuncturists cannot become Medicare providers without Congress changing the law, something our profession has been trying to get them to do for a couple of decades now. So that is where our efforts are directed, but it does nothing to help patients in the near term.

Insurance companies have responded in some cases by adding similar coverage that allows patients to go to regular acupuncture offices. Different plans use different strategies, so if this includes your insurer, I can’t tell you anything about your specific plan. I can tell you that in central New Mexico, Presbyterian Senior Care has long covered acupuncture (though a limited number of sessions per year and with low reimbursement) for most if not all conditions, and Blue Cross Blue Shield and United also have some plans with reasonable or even quite good coverage. Presbyterian also now covers 12 sessions for dual eligibles, people with both Medicare and Medicaid, who are among the most vulnerable in our population. In most cases Medicaid gives no coverage at all for acupuncture— mostly because the lack of Medicare coverage means no federal dollars are available— so this is a small but significant step forward.

Despite its severe limitations, that CMS decision early last year was a sea change, much more than the baby step it has been in practical terms. Only a few years earlier, there was a petition to the federal government asking for Medicare coverage of acupuncture, which gained over 100,000 signatures and thus required a response. The response CMS gave was utterly dismissive, stating that acupuncture was not necessary or effective for any condition. This came from a milieu in which the government itself was sponsoring research on acupuncture and our work was becoming more and more common, accepted, and proven, so it felt like a painful and bizarre slap in our faces. And it made the sudden reversal at the beginning of 2020 all the more stunning.

(In contrast, the VA not only covers acupuncture but employs acupuncturists in its facilities, so you can see how far behind CMS is.)

Here is a memo from CMS to providers. This document doesn’t make it clear that acupuncturists cannot be Medicare providers, so it seems to me that it adds still more confusion. I suppose the providers to whom it is directed already understand this, though.
https://www.cms.gov/files/document/mm11755-national-coverage-determination-ncd-3033-acupuncture-chronic-low-back-pain-clbp.pdf

And here is a benefits summary for 2022 for a group of Presbyterian plans, which a number of my patients have:
https://contentserver.destinationrx.com/ContentServer/DRxProductContent/PDFs/177_0/2022%20Senior%20Care%20HMO%20Plans%20Summary%20of%20Benefits.pdf

You can see that there is a listing for “Medicare covered” acupuncture as separate from “Routine” acupuncture, but zero explanation of what that means or how many visits are allowed under that section. I assume that members receive a more complete description of their coverage as well, but this almost guarantees that they will be confused.

(You can also see that there are two tiers for chiropractic treatment. This, too, reflects what is covered by Medicare and what is not, but the typical reader would never know that from the way it’s worded.) 

I doubt you’ll be surprised to hear that we Doctors of Oriental Medicine were never told that Presbyterian was allowing any extra “Medicare covered” sessions— or even that the allowed “Routine” sessions had been increased from 20 to 25. A patient of mine found out about it quite recently and let me know. For those with severe, chronic problems, 25 treatments a year may not be enough, so this could be a real help.

I’m cautiously optimistic about the future of acupuncture access, but when people talk about Medicare for All, I advocate for Something Better than Medicare, for All.

You can help acupuncturists to become Medicare providers by learning about HR 4803, the Acupuncture for Our Seniors Act, and contacting your representative. Much more will be going on with this in the coming year.

https://www.asacu.org/wp-content/uploads/Medicare-Recognition-H.R.-4803.pdf

Delta Blues, or how I spent my summer not being able to take a vacation

Elene Explores

We still need all of these layers.

When I started writing this post, I was planning on a straightforward update on the current situation with the delta variant (sorry, I couldn’t resist the obvious title). And then a 13-year-old killed a classmate at a local middle school for no discernible reason. And then the Taliban took back Afghanistan.

The murdered boy was trying to talk his killer out of continuing to bully his friends. He stood up to him with words, doing exactly what most of us would teach our kids to do, what my daughter would do, what I would do. The right thing.

Going into Afghanistan was never the right thing. I remember writing “Can you say ‘quagmire’?” back then. Three quarters of Americans thought this war was a great idea. I was part of the other quarter. I take no pleasure in being right in this case…

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Don’t “Panic,” But We’re Not Done with This Yet. Not Even Close.

Elene Explores

Best New Mexican conspiracy theory. The booster has microguacamole.

Last week we got the news that a little girl, under 10 years of age, died of COVID-19 in our state. Because of privacy concerns, all we know is that she had underlying conditions and was hospitalized. Kids her age are of course not being vaccinated as yet, one more reason we still need to be careful. This is not over, not by a long shot.

I started writing this post in early April, then ended up working on other matters and putting it off for an unconscionably long time. Many things about the pandemic have become clearer since then, while others have become muddier still.

At that time a few months ago, COVID-19 was doing its maximum damage in India, and Brazil was not far behind. There were still influential voices referring to the pandemic as a “panic,” implying that…

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Mask Confusion, Mask Destruction?

Elene Explores

This part at least is clear!

 

I’m just coming off a session of attempting to de-freakout someone about a misleading vaccine scare article. I’ve had it with the antivaxx disinformation crew, and then I’ve also had it with the “science-based” bunch who poo-poo everything that doesn’t fit their narrow field of vision, like the guy I was reading a few minutes ago who insists that chiropractors aren’t doctors. I’ve had it.

I bet you’ve had it too.

Let’s take a deep breath, get a cup of tea, and survey the current state of play in our pandemic reality.

 

Are you confused about where, when, and whether to wear a mask now, or whether they help at this point? Of course you are. The current guidance is about as confusing as anything in the past 15 months has been, though I don’t know how it could be stated much…

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Sorting Medical Fact from Fiction, Part III: Give Me Liberty AND Give Me Death

Elene Explores

Patients have been asking me about “herd mentality,” which they then quickly correct to “herd immunity.” Herd mentality we’ve got plenty of. Herd immunity, not so much. In fact, it’s unclear whether widespread, lasting natural immunity to COVID-19 is even a biological possibility. It may turn out to be only a mirage.

But as the pandemic drags on and we are all getting weary, some of us are worn down enough to entertain some pretty crazy notions– or to take cynical advantage of our weariness.

The Great Barrington Declaration came out on October 4, made a splash, and is still being talked about. This is a letter which calls for letting the virus essentially run wild among the younger and healthier members of the population, in order to bring about a theoretical herd immunity, while in some way protecting those who are at high risk. It’s named for Great Barrington…

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Sorting Medical Fact from Fiction, Part II: We Need Therapy

Elene Explores

About the time I began writing this, at the annual meeting of our New Mexico Society for Acupuncture and Asian Medicine, we heard a presentation from David Riley, MD about how to write case reports for publication in medical journals. That brought home to me how much goes into each published study that we read and how slow and incremental the scientific process can be.

At the same meeting, one of my senior colleagues went into a passionate rant about how the SARS-CoV-2 virus was engineered as a bioweapon and we are at war, hydroxychloroquine was great, we should all go to Fox News and Newsmax to get The Truth, and most stunning of all, that President Trump was the highest order of doctor because he saved the lives of the people of America by instituting a travel ban.

The rest of us sat there and gazed bemusedly at our…

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Sorting Medical Fact from Fiction, Part I: The Two Earths

Elene Explores

No, not the Silurians.

A couple of decades ago, a friend introduced me to the work of a person who was then known as Anna Hayes. Supposedly her teachings were “downloaded” (not channeled, she said) from a galactic council of aliens who were trying to be helpful to humanity and fight other aliens, including that perennial mainstay the reptilians, who were working to keep us confused and divided. Following her and doing the practices she taught was supposed to raise people’s vibratory states and allow them to rise above these malevolent influences and create a better reality.

Some of her practices appeared to be worthwhile for one’s health. Some of the very, very dense verbiage involved was obviously crap. And a lot was so hard to understand that one might not be quite sure. There was one contention she had that keeps coming up in my mind, though: a prediction…

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When We Used to Dance

Two Halloweens ago.  I haven’t been part of a live performance since February this year.

Dance is a huge help to my mental and physical health.  Although it’s not quite the same, there is still plenty going on with dance classes and performances in the virtual world.  I encourage you to move to music in any way that inspires you.  There’s nothing better for body, mind and spirit!

What Are Viruses? In a Way They Are Us

Elene Explores

Coronavirus structure. An artistic response to the last SARS epidemic, in glass. https://www.lukejerram.com/glass/gallery/sars-corona-virus

At the beginning of the year, I wrote about the goddess Kali, having no idea how soon she’d be coming after us.

I also wrote about the interconnectedness of everything on the planet and everywhere, and how the dichotomy of humans vs. nature is false.

It turns out that even the dichotomy of viruses vs. us is false. We all learned in school that viruses are tiny beings that exist in a strange twilight zone between the living and the nonliving, and that they can’t reproduce without using the machinery of plant or animal cells. I hadn’t followed that thought to its conclusion, which is that since viruses must build themselves out of the materials of our own cells, they are in a sense made out of us. They, too, are inextricably entwined with ourselves.

This came…

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Have You Been Saddled with a Garbage Can Diagnosis? by James Rolwing

This stuff does happen often. Sometimes it’s just plain hard to pin down what’s really going on, but often there is a lack of attention and thought.

Pattern Release Energetics

This is the second part in a series that focuses on “garbage can diagnoses” (see Part I for a more detailed description of what constitutes a GCD.)

TMJ: (properly known as temporomandibular joint disorder) “My doctor/dentist says I have TMJ.” Gawd, I wish I had a dollar (nickel adjusted for inflation) for every time I’ve heard this one. Of course, they never follow up this statement with how it’s being treated, because most practitioners don’t know what to do with this condition besides give you a mouth guard. Great, now I can play hockey without losing my teeth, but my jaw still hurts. This GCD could include everything from jaw clicking, locking, joint pain, and nighttime clenching and grinding.

The importance of the jaw in overall health can’t be overstated. Because of the intense concentration of nerve receptors in the jaw that monitor proprioception–the body’s ability to sense…

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