Acupuncture Guidelines

eviCore covers therapeutic acupuncture (manual and electro‑acupuncture) for specified primary neuromusculoskeletal diagnoses (cervical, thoracic, lumbosacral, extremity conditions) and certain selected adjunct non‑musculoskeletal indications if covered by the member's plan, while excluding maintenance, palliative‑only, preventive, experimental services, numerous listed diagnoses/services (e.g., some now‑excluded conditions, imaging, supplements, and electro‑acupuncture >9 volts) and services outside plan coverage. Coverage requires eviCore medical‑necessity documentation showing the symptoms are directly due to a primary neuromusculoskeletal condition, care by a licensed clinician, objective baseline findings and measurable progressive improvement (pain scores, PSFS/functional measures), adherence to specified week‑by‑week progress benchmarks, red‑flag rule‑outs/referrals, and submission of the Acupuncture Treatment Request Form for continued treatment.

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