Acupuncture Guidelines

eviCore covers acupuncture and electro‑acupuncture only when therapeutic/corrective and medically necessary to treat a covered primary neuromusculoskeletal injury or illness (e.g., cervicogenic headache, cervicocranial syndrome, neuromusculoskeletal migraine, cervical radiculopathy, and specified cervical/thoracic/lumbar diagnoses) and excludes maintenance, palliative, preventive, experimental services, many administrative/plan exclusions (including inpatient care, advanced diagnostics, certain unsupported conditions, and electro‑acupuncture >9 volts). Coverage requires thorough, legible documentation linking symptoms to a covered diagnosis (history/exam, numeric pain scale, Patient Specific Functional Scale, objective findings), use of eviCore’s Acupuncture Treatment Request Form, an initial 2–4 week trial with week‑by‑week progress benchmarks and documented percent/functional improvement for continued authorization, and appropriate referral/co‑management when red flags are present.