Acupuncture Guidelines

Acupuncture and electro‑acupuncture are covered only when eviCore determines they are medically necessary, therapeutic/corrective for primary neuromusculoskeletal conditions (and certain listed adjunct indications); maintenance/palliative/preventive care, inpatient or experimental services, certain excluded conditions (e.g., carpal tunnel, fibromyalgia, ankle sprain, mild hyperemesis gravidarum) and prohibited techniques (e.g., electro‑acupuncture >9V, scarring moxa, applied kinesiology, osseous manipulation in Tui Na) are not covered. Coverage requires the eviCore Acupuncture Treatment Request Form and adequate documentation (history, exam, numeric pain scores, objective functional measures such as PSFS, progress notes) demonstrating measurable, time‑bound improvement and appropriate co‑management for children ≤14.

"Lumbar Degenerative Disc Disease (recurrent/episodic/chronic low back pain > 3 months, occasionally with sciatica)."