Practitioner view of CMS decision on acupuncture for low back pain

By Bill Reddy, LAc, DiplAc

On January 21, the Centers for Medicare and Medicaid Services (CMS) finalized its decision to cover acupuncture for low back pain. As reported earlier this year on Integrative Practitioner, CMS released a 41-page decision memo defining low back pain, licensing requirements, and the number of sessions the agency will cover per year.   

According to the decision, CMS will cover a maximum of 20 acupuncture sessions per year for beneficiaries with nonspecific, chronic lower back pain, providing pain patients with an alternative to opioids. The agency defines low back pain as pain that lasts 12 weeks or longer, has no identifiable systemic cause, and is not associated with surgery or pregnancy. Under the decision, Medicare will cover up to 12 acupuncture sessions in 90 days for qualifying beneficiaries and will cover an additional eight sessions for qualifying beneficiaries who demonstrate improvement after the acupuncture treatments. However, CMS said treatments will be discontinued if the patient is not improving.

The acupuncture community has expressed concerns about reimbursement rates, since Medicare is known to pay roughly 25 percent less than private insurers. Insiders suggest the range will be between $24 and $36 per treatment, or per unit of time, which makes a difference, depending on the geographic location of the practitioner. It is currently unknown if any examination or office visit codes will be allowed.

Another concern is the 60 million Medicare beneficiaries’ access to acupuncture providers. Medical doctors, osteopathic doctors, and chiropractic doctors are allowed to practice acupuncture with as little as 100 hours of training, but there are no current accurate counts of physicians and chiropractors offering acupuncture in literature. The decision memo limits those who can provide acupuncture services to physicians and licensed acupuncturists.

Acupuncturists are not randomly distributed across the United States but are usually found practicing in busy urban centers and residing in those states with the most acupuncture schools. In a 2018 study, researchers estimated the total number of licensed acupuncturists in the U.S. was a little less than 38,000. However, there was no indication of what percentage of those acupuncturists practice fulltime, part-time, or at all, which may further affect access. 

There are acupuncturists licensed in multiple states, which makes estimating an exact number difficult. Alabama, South Dakota, and Oklahoma currently do not have practice acts for acupuncturists, so only physicians may offer services to Medicare recipients in those states. For comparison, there were 295 physicians per 100,000 Americans in 2016, almost 30 times that of licensed acupuncturists.

The numbers represent practitioners per 100,000 U.S. citizens, not Medicare patients. There were 60 million Medicare beneficiaries in the U.S. in 2018, representing 18 percent of the total population. If the number of acupuncturists were to be measured against the Medicare population, it would rise to 21 per 100,000 nationally.

The decision defines licensed acupuncturists as auxiliary personnel. Acupuncturists are currently not an “approved provider” as listed in the current Social Security Act statutes. As such, auxiliary personnel furnishing acupuncture must be under an appropriate level of supervision by a physician, physician assistant, or nurse practitioner as required by regulations 42 CFR §§ 410.26 and 410.27.

Since more than 90 percent of all acupuncturists practice in a private setting, finding an appropriate supervisor could be a logistical and accounting nightmare. Although a “supervisor” is not required to be co-located with the acupuncturist, they would still be required to receive the reimbursement for the service then relay that payment to the acupuncturist. This supervision requirement would be in place until Congress passes legislation adding acupuncturists as an approved provider under the Social Security Act.

The acupuncture community is awaiting final directives from CMS as to exactly how this new benefit will be administered, as those details are yet to be determined. This is an expansion of services for Medicare, and there will naturally be some delays in clarifying the details of the complete rollout.

CMS was as generous as it could be in providing allowances for the inclusion of licensed acupuncturists in the provision of care, but there are some outstanding issues that must be addressed when implementing this new coverage plan. However, if Medicare covers a service, private insurers typically follow suit. All in all, this additional benefit appears to represent profound progress for the acceptance and availability of acupuncture in the United States. Acupuncture is an “essential health benefit” in accordance with the Affordable Care Act in six states, which means that 100 percent of insurance companies cover acupuncture services. 

Progress, while slow, is still movement forward. With increased availability and, in time, the resolution of implementation barriers, the availability of acupuncture will help reduce opioid use and abuse.