Does 97814 require prior authorization?

No, 97814 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 97814?

Medicare facility rate: $21.04. Non-facility rate: $28.72. Work RVU: 0.47.

Verity

`97814`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.47

Facility

$21.04

Non-Facility

$28.72

Documentation Required

Documentation that the patient's diagnosis meets one of the covered indications (e.g., chronic neck pain or chronic headache with minimum 12 weeks duration where applicable).
Documentation of duration of symptoms when chronicity is required (policy explicitly requires minimum 12 weeks duration for chronic neck pain and chronic headache).
Documentation of clinical response: if no clinical benefit after four weeks of acupuncture, the treatment plan should be reevaluated; further treatment is not medically necessary if the member does not demonstrate meaningful improvement in symptoms.
Provider credentialing/license documentation showing the acupuncture is administered by a health care provider practicing within the scope of his/her license (and, where applicable by specific plans, documentation that provider is a legally qualified physician practicing within scope of license).

Key Coverage Criteria

Plantar Fasciitis
Peptic Ulcer
Post-Operative Ileus
Post-Prandial Distress Syndrome
Post-Stroke Shoulder Pain
Premature Ejaculation

20 Active Policies

AMBETTER-CP.BH.124 — Attention Deficit Hyperactivity Disorder Assessment and Treatment

AETNA-CPB-0069 — Lymphedema

AETNA-CPB-0327 — Infertility

AETNA-CPB-0362 — Spasticity Management

AETNA-CPB-0374 — Trigeminal Neuralgia: Treatments

Have a follow-up question?

Ask Verity about documentation requirements, denial risks, or coverage in your state.

When billing, use of covered CPT/HCPCS codes only when selection criteria are met (97810, 97811, 97813, 97814; S8930) and documentation linking billed service to covered diagnosis and to the selection criteria.

For services excluded/considered experimental (e.g., dry needling, acupuncture point injection for listed conditions, TDP lamp adjunct), documentation supporting medical necessity would not meet coverage per policy; plan-level benefit checks required.

AETNA-CPB-0431 — Enuresis

AETNA-CPB-0457 — Dry Eyes

AETNA-CPB-0676 — Electrical Stimulation for Nausea, Vomiting and Motion Sickness (PrimaBella and ReliefBand) and Other Selected Indications

AETNA-CPB-0789 — Acute Ischemic Stroke Treatments

CIGNA-CPG024 — Acupuncture - (CPG024)

AETNA-CPB-0039 — Weight Reduction Programs and Devices

AETNA-CPB-0135 — Acupuncture and Dry Needling

AETNA-CPB-0235 — Plantar Fasciitis Treatments

AETNA-CPB-0302 — Xerostomia: Selected Treatments

AETNA-CPB-0304 — Fibroid Treatment

AETNA-CPB-0369 — Chronic Fatigue Syndrome

AETNA-CPB-0406 — Tinnitus Treatments

AETNA-CPB-0504 — Hyperhydrosis

AETNA-CPB-0511 — Eating Disorders

AETNA-CPB-0512 — Premenstrual Syndrome and Premenstrual Dysphoric Disorder

97814