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