The Centers for Medicare & Medicaid Services (CMS) has announced that Medicare will now cover acupuncture for patients with chronic low back pain in part because of the widespread abuse of opioids in America. Medicare will now cover up to 12 sessions in 90 days with an additional 8 sessions for those patients with chronic low back pain who demonstrate improvement. Until now, acupuncture was not covered by Medicare.
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“Expanding options for pain treatment is a key piece of the Trump Administration’s strategy for defeating our country’s opioid crisis,” US Department of Health and Human Services (HHS) Secretary Alex Azar said in a statement. “President Trump has promised to protect and improve Medicare for our seniors, and deciding to cover this new treatment option is another sign of that commitment. Medicare beneficiaries will now have a new option at their disposal to help them deal with chronic low back pain, which is a common and sometimes debilitating condition.”
A federal agency in the HHS, CMS administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (CHIP), and health insurance portability standards.
“We are dedicated to increasing access to alternatives to prescription opioids and believe that covering acupuncture for chronic low back pain is in the best interest of Medicare patients,” said CMS Principal Deputy Administrator of Operations and Policy Kimberly Brandt in a statement. “We are building on important lessons learned from the private sector in this critical aspect of patient care. Over-reliance on opioids for people with chronic pain is one of the factors that led to the crisis, so it is vital that we offer a range of treatment options for our beneficiaries.”
The CMS announced this week that its decision to cover acupuncture was the result of an examination of coverage policies of private payers and takes into account an assessment of benefits and harms and the opioid public health crisis. And while there is variation in what’s covered and the allowed number of visits to acupuncturists among private payers, a large number of them provide some coverage of acupuncture, CMS reported.
“While a small number of adults 65 years of age or older have been enrolled in published acupuncture studies, patients with chronic low back pain in these studies showed improvements in function and pain. The evidence reviewed for this decision supports clinical strategies that include non-pharmacologic therapies for chronic low back pain,” CMS reported.
Some 47,600 deaths related to overdose involved opioids in 2017, the CMS reported. The CMS said it is now “keenly focused on fighting the opioids epidemic including by supporting access to pain management using a safe and effective range of treatment options that rely less on prescription opioids.”
The CMS said it has made “significant strides” in preventing opioid use disorder by, for example, issuing safety alerts to pharmacists when a beneficiary’s opioids prescription exceeds certain levels. “Given these and other efforts from federal partners, total opioids dispensed by pharmacies nationwide declined 31 percent since 2017,” CMS reported.
Practitioners of acupuncture—a form of alternative medicine and a key component of traditional Chinese medicine—stimulate strategic points on the body, most often by inserting thin needles through the skin. The alternative therapy is most commonly used to treat pain but is increasingly being used for overall wellness and stress management.
According to Mayo Clinic, “traditional Chinese medicine explains acupuncture as a technique for balancing the flow of energy or life force—known as chi or qi (chee)—believed to flow through pathways (meridians) in your body. By inserting needles into specific points along these meridians, acupuncture practitioners believe that your energy flow will re-balance. In contrast, many Western practitioners view the acupuncture points as places to stimulate nerves, muscles and connective tissue. Some believe that this stimulation boosts your body's natural painkillers.”
Whatever the reason, reviews on its effectiveness are also mixed, and many want even more alternative therapies covered.
“To me, the best therapy is chiropractic and massage therapy,” said Bonnie Huffman. “Massage therapy should be covered. The benefits of it are remarkable. I have had successful back surgery, and I would not be working if it wasn’t for my chiropractor and massage therapist. I have tried the needles. They don’t work for me, but I know people that they do work for.”
“I tried [acupuncture] once on the reference of a pain management doctor to a physical therapist,” said Lois Martin. “She hit a nerve, and that did not feel good at all. Couldn’t tell any difference even after the treatment. She was young and may have been inexperienced. Chiropractic has given best results. Massage therapy would be awesome but it’s expensive and not covered. I think it would speed up recovery after a flair up.”
Currently, Medicare only covers chiropractic care as a treatment for a condition called spinal subluxation. According to the latest information regarding Medicare coverage in 2020 from AARP, “original Medicare pays for only one chiropractic service: manual manipulation of the spine if deemed medically necessary to correct a subluxation (when one or more of the bones in your spine are out of position). This procedure, when performed by a chiropractor or other qualified provider, is covered through Medicare Part B, the component of original Medicare that includes outpatient services.”
Medicare will pay 80% of the Medicare-approved rate for this procedure, and you will owe 20% of the amount. In addition, you must also pay your deductible for Part B before Medicare begins to pay its share. You pay all the costs for other services provided or tests that a chiropractor orders, including massage therapy and X-rays. Medicare will cover the cost of an X-ray a physician orders to demonstrate that a spinal subluxation requires treatment but will not if a chiropractor ordered the X-ray. Some Medicare Advantage plans do offer routine chiropractic services, however, as an additional benefit.
According to Mayo Clinic, acupuncture has been used to relieve discomfort associated with a variety of diseases and conditions, including:
- Chemotherapy-induced and postoperative nausea and vomiting
- Dental pain
- Headaches, including tension headaches and migraines
- Labor pain
- Low back pain
- Neck pain
- Osteoarthritis
- Menstrual cramps
- Respiratory disorders, such as allergic rhinitis
The risks of acupuncture are low as long as patients seek a competent, certified acupuncture practitioner who uses sterile, one-time use needles. Common side effects could include soreness and minor bruising or bleeding at the site where the needles were inserted.
Still Mayo Clinic cautions that not everyone is a good candidate for acupuncture. You may be at risk of complications if you:
- Have a bleeding disorder. Your chances of bleeding or bruising from the needles increase if you have a bleeding disorder or if you're taking blood thinners.
- Have a pacemaker. Acupuncture that involves applying mild electrical pulses to the needles can interfere with a pacemaker's operation.
- Are pregnant. Some types of acupuncture are thought to stimulate labor, which could result in a premature delivery.
Mayo Clinic recommends taking the same steps in choosing an acupuncturist that you would if you were choosing a new doctor:
- Ask people you trust for recommendations.
- Check the practitioner's training and credentials. Most states require that nonphysician acupuncturists pass an exam conducted by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM).
- Tell your doctor you're considering acupuncture. He or she may be able to tell you about the success rate of using acupuncture for your condition or recommend an acupuncture practitioner.
And not everyone responds to acupuncture.
“Many people who have chronic low back pain have found acupuncture to be helpful. But the scientific evidence to support these claims has been mixed, partly because it can be difficult to devise a good form of sham acupuncture for comparison,” said Brent A. Bauer, M.D.
According to the National Center for Complementary and Integrative Health (NCCIH), several studies indicate that both traditional (actual) and simulated (sham/placebo) acupuncture decrease pain, but other studies have suggested that the neural mechanisms involved may be different. (Simulated acupuncture mimics actual acupuncture, but without piercing the skin or using specific points.) There is evidence that simulated acupuncture appears to work just as well as real acupuncture. Evidence also shows that acupuncture works best in people who expect it to work.
“Scientific studies have indicated that sham acupuncture works just as well as real acupuncture for back pain,” Bauer said. “This could mean that sham acupuncture…could be having an effect, or it could mean that the effects of acupuncture may be due in part to a placebo effect.”
Bauer said the research on acupuncture is growing, but interpreting it is still a challenge. “For now, most studies seem to indicate that, for most people, acupuncture results in some beneficial effect with a low risk of side effects when provided by a well-trained practitioner. So if other treatments haven't helped your low back pain, it may be worth trying acupuncture. But if your back pain doesn't begin to improve within a few weeks, acupuncture may not be the right treatment for you.”
Mayo Clinic has ongoing studies testing treatments for pain management, including acupuncture.
For the purpose of the CMS decision, chronic low back pain is defined as:
- Lasting 12 weeks or longer;
- nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
- not associated with surgery; and
- not associated with pregnancy.
Physician assistants, nurse practitioners/clinical nurse specialists and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:
- A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
- current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.
