Acupuncture Guidelines

eviCore covers acupuncture/electro‑acupuncture only when therapeutic/corrective and medically necessary for primary neuromusculoskeletal diagnoses (e.g., cervicogenic headaches, cervical/thoracic/lumbosacral spine and many extremity conditions) and selected plan‑reviewed non‑musculoskeletal indications, while excluding palliative/maintenance/preventive care, experimental services, many diagnostic/ancillary items, services outside the plan scope (workers’ comp, auto claims, out‑of‑network), electro‑acupuncture >9 volts, and techniques outside provider/state scope. Coverage requires detailed, legible documentation of medical necessity linking symptoms to a primary neuromusculoskeletal condition, objective exam findings, numeric pain scores and PSFS functional measures, the eviCore Acupuncture Treatment Request Form, demonstration of expected improvement per specified weekly benchmarks (with medical co‑management for children ≤14 and many post‑op cases), and discontinuation if progress or compliance criteria are not met.