Acupuncture

Acupuncture (CPG 024)

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Cigna Medical Coverage Policy- Therapy Services

Acupuncture

Effective Date: 4/15/2023

Next Review Date: 4/15/2024

INSTRUCTIONS FOR USE

Cigna / ASH Medical Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by

Cigna Companies. Please note, the terms of a customer’s particular benefit plan document may differ significantly from the standard

benefit plans upon which these Cigna / ASH Medical Coverage Policies are based. In the event of a conflict, a customer’s benefit plan

document always supersedes the information in the Cigna / ASH Medical Coverage Policy. In the absence of a controlling federal or

state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Determinations in each

specific instance may require consideration of:

1) the terms of the applicable benefit plan document in effect on the date of service

2) any applicable laws/regulations

3) any relevant collateral source materials including Cigna-ASH Medical Coverage Policies and

4) the specific facts of the particular situation

Cigna / ASH Medical Coverage Policies relate exclusively to the administration of health benefit plans.

Cigna / ASH Medical Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines.

Some information in these Coverage Policies may not apply to all benefit plans administered by Cigna. Certain Cigna Companies

and/or lines of business only provide utilization review services to clients and do not make benefit determinations. References to standard

benefit plan language and benefit determinations do not apply to those clients.

Acupuncture is subject to the terms, conditions and limitations of the benefits as described in the

applicable plan’s schedule of copayments. Please refer to the applicable benefit plan document to

determine benefit availability and the terms and conditions of coverage.

GUIDELINES

ACUPUNCTURE

Medically Necessary

If coverage for acupuncture services are available in the applicable benefit plan document, acupuncture

may be provided as treatment for ANY of the following conditions when ALL of the medical necessity

factors and ALL of the treatment planning /outcomes listed below are met:

• Tension-type Headache; Migraine Headache with or without Aura

• Musculoskeletal joint and soft tissue pain (e.g., hip, knee, spine) resulting in a functional deficit (e.g.,

inability to perform household chores, interference with job functions, loss of range of motion)

• Nausea Associated with Pregnancy (only when co-managed)

• Post-Surgical Nausea (only when co-managed)

• Nausea Associated with Chemotherapy; (only when co-managed)

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Medical Necessity Factors:

• Medically necessary services must be delivered toward defined reasonable and evidence-based goals;

• Medical necessity decisions must be based on patient presentation including diagnosis, severity, and

documented clinical findings;

• Continuation of treatment is contingent upon progression towards defined treatment goals and

evidenced by specific significant objective functional improvements (e.g., outcome assessment scales,

range of motion)

• Certain conditions require that the patient is being co-managed by a medical physician in order to be

considered medically necessary;

• Medically necessary services including monitoring of outcomes and progress with a change in treatment

or withdrawal of treatment if the patient is not improving or is regressing.

Treatment Planning/Outcome Factors:

• An individualized treatment plan (e.g., frequency and duration of service) is appropriately correlated with

clinical findings and clinical evidence;

• Treatment is expected to result in significant therapeutic improvement over a clearly defined period of

time;

• Therapeutic goals are functionally oriented, realistic, measurable, and evidence-based;

• Proposed date of release/discharge from treatment is estimated;

• Functional Outcome Measures (FOM)*, when used, demonstrates Minimal Clinically Important

Difference (MCID) from baseline results through periodic re-assessments;

• Documentation substantiates practitioner’s diagnosis and treatment plan;

• Demonstration of progression toward active home/self-care and discharge, and;

• Maximum therapeutic benefit has not been reached.

*Not all outcome measures have MCID’s determined and supported in the literature. Actual significance of these

findings requires correlation with the overall clinical presentation, including updated subjective and objective

examination findings

Not Medically Necessary

Acupuncture is considered not medically necessary for any of the following indications:

• Treatment intended to improve or maintain general physical condition

• Maintenance acupuncture services, when significant therapeutic improvement is not expected

• Services that do not require the skills of a qualified provider of acupuncture including but not limited to:

 Activities and services that can be practiced independently and can be self-administered safely

and effectively.

 Home exercise programs that can be performed safely and independently to continue therapy

without skilled supervision.

Experimental, Investigational, Unproven

Acupuncture for any other indication, including infertility and recurrent pregnancy loss, is considered

experimental, investigational or unproven.

ACUPUNCTURE POINT INJECTION THERAPY

Acupuncture point injection therapy is considered experimental, investigational or unproven.

DESCRIPTION AND BACKGROUND

Acupuncture (CPG 024)

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Acupuncture is a form of complementary and alternative medicine that has been widely practiced for many

centuries. It involves the stimulation of specific anatomical locations on the skin through the penetration of fine

needles, with the goal of relieving pain or treating disease. Stimulation can be accomplished manually (i.e., by a

twisting motion of the hand) or through such methods as electrical stimulation (i.e., electroacupuncture). The

practice of traditional acupuncture is predicated upon several fundamental underlying principles. It is predicated

upon the existence of a series of meridians that course through the body along which are located discrete points

that correspond to specific organs and/or have particular clinical significance. A vital energy, “chi,” flows through

the meridians and the acupuncture points and regulating bodily functions. It is the disruption of this flow of

energy that therapeutic acupuncture is said to address.

Acupuncture typically utilizes unique diagnostic procedures to evaluate the meridian/chi system. This includes

an evaluation of the patient’s chief complaint and related health status through standardized diagnostic

interviewing and examination techniques. Interviews are based on the traditional Ten Questions and

examinations include, but are not limited to, evaluation of meridians, points, general vitality and behavior, the

radial pulses and the tongue. Based upon the patient’s complaint and the findings of these diagnostic

procedures, individualized treatment regimens are developed that specify treatment variables such as the

acupuncture points to be utilized, needle placement, and type of needle stimulation.

A majority of states provide licensure or registration for acupuncture practitioners, although the scope of practice

allowed under state requirements varies. Depending upon the jurisdiction, those licensed to administer

acupuncture may include licensed acupuncturists (LAc), medical/osteopathic physicians (MD/DO), chiropractors

(DC), naturopaths (ND), oriental medicine doctors (OMD), podiatrists (DPM), dentists (DDS/DMD), nurse

practitioners (NP), physician assistants (PA), as well as other designated health care providers. Depending

upon the practitioner’s training, different systems of acupuncture diagnosis and treatment may be used. The

National Institutes of Health (NIH) Consensus Panel and the U.S. Food and Drug Administration (FDA) consider

acupuncture safe when performed by qualified practitioners using sterile needles. The FDA requires that sterile,

nontoxic needles be used and that they be labeled for single use by qualified practitioners. Acupuncture appears

to be a relatively safe treatment with rare serious adverse side effects when performed by qualified practitioners

who consistently adhere to the recommendations of the FDA regarding the use of sterile needles.

Depending on the pain condition being treated, a course of acupuncture may last several weeks. Although there

is no consensus in the scientific literature regarding the optimal number of acupuncture treatments to administer

or the duration of treatment for any condition, in general, there should be a reasonable expectation for clinical

improvement. If no improvement is documented after an initial trial of two-four weeks treatment, an alternative

treatment plan should be considered. If lack of clinical improvement continues following subsequent treatments

re-evaluation by the referring provider may be indicated. If measurable objective improvement is made, then

progress towards identified goals should be clearly documented and the treatment plan updated accordingly.

The necessity of continued care beyond a therapeutic trial is dependent upon objective evidence of

improvement (i.e., functional gain).

Multiple different biological mechanisms have been proposed and studied to explain acupuncture. All of these

proposed mechanisms are centrally mediated and not merely local physiologic responses. Most commonly it is

thought that the stimulation of the acupuncture needle triggers the release of endogenous opioids (endorphins).

This effect seems the most pronounced in electro-acupuncture. Another possible mechanism is through the

diffuse noxious inhibitory control pathway (DNIC). According to DNIC, a noxious stimulus applied to any region

of the body can induce immediate suppression of pain transmission in neurons of the trigeminal caudalis and/or

the spinal dorsal horn. Another theory proposes that the descending serotoninergic inhibitory pathway is key to

acupuncture analgesia. In addition, there is some preliminary evidence that acupuncture may have effects on

the inflammatory response mediated through the autonomic nervous system. Current available evidence

indicates that insertion of acupuncture needles has an effect above waiting list controls but there is limited

available evidence to define whether exact needle placement on established “Traditional” Acupuncture points is

necessary to produce a result.

None of the mechanisms of action postulated for acupuncture affects are sufficiently well understood to have

established a dispositive answer to describe the exact physiological mechanism by which acupuncture produces

its analgesic and antiemetic effects.

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Acupuncture Point Injection Therapy: Acupuncture point injection therapy is a procedure where

pharmaceuticals and natural biologic products such as vitamins, herbal extracts and other homeopathics, are

injected into the body at acupuncture points to prevent or treat disease. One solution in particular, isotonic

saline, when injected theoretically allows activation of the acupuncture point for a longer period of time

enhancing the therapeutic effect.

DOCUMENTATION GUIDELINES

Evaluation: An initial evaluation service is essential to determine whether any acupuncture services are

medically necessary, to gather baseline data, establish a treatment plan, and develop goals based on the data.

The initial evaluation service must include: An appropriate level of clinical history, examination, and medical

decision-making relevant and appropriate to the individual’s complaint(s) and presentation;

• Subjective historical evaluation based on standardize method such as the 10 questions;

• Specific standardized and non-standardized tests, assessments, and tools;

• Interpretation and synthesis of all relevant clinical findings derived from history and physical examination

for the purpose of clinical decision-making;

• Subjective and objective measurable, description of functional status using comparable and consistent

methods;

• Summary of clinical reasoning and consideration of contextual factors with recommendations;

• The establishment of a working diagnosis;

• Plan of care with specific treatment techniques or activities to be used in treatment sessions that should

be updated as the individual's condition changes;

• Frequency and duration of treatment (treatment dose);

• Functional, measurable, and time-framed long-term and short-term goals based on appropriate and

relevant evaluation data; and

• Prognosis and discharge plan.

Treatment Sessions: Acupuncture treatment can vary from Acupuncture alone (CPT codes 97810, 97811,

97813, 97814) to the use of a variety of modalities and procedures depending on the patient’s condition,

response to care, and treatment tolerance. All services must be supported in the treatment plan and be based

on an individual’s clinical condition. An acupuncture treatment session may include:

• A brief evaluation of the patient’s progress and response to previous treatment(s);

• Acupuncture with or without electric stimulation

• Related passive modalities (e.g.: indirect moxibustion, hot/cold packs

• Functional education in self-care and home management

• Reassessment of the individual's condition, diagnosis, plan, and goals as part of the treatment session

• Coordination, communication, and documentation

• Reevaluation, if there is a significant change in the individual's condition or there is a need to update

and modify the treatment plan

Documentation of treatment sessions should include at a minimum:

• Date of treatment

• Specific treatment(s) provided that match the procedure codes billed

• Total treatment time

• The individual's response to treatment

• Skilled ongoing reassessment of the individual's progress toward the goals

• Any progress toward the goals in objective, measurable terms using consistent and comparable

methods

• Any barriers to expected progress or changes to the plan of care

• Name and credentials of the treating clinician

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Measuring Progress in Acupuncture: Monitoring for clinically significant changes in historical/examination

findings and functional status including, but not limited to:

• Pain level per VAS 1-10 scale and Frequency of symptoms

• Reported interference with daily functional activities

• Validated Functional Outcome Measures specific for condition (Clinically significant therapeutic progress

(MCID, improvement in pain, impairments and objective evaluation findings)

• Length of time of relief after treatment rendered

• Monitoring for significant changes in reported patient medication or other resource utilization

• Tenderness on palpation

• Range of motion

• Observation (e.g. behavior, mobility, appearance of affected area)

• Barriers to expected progress (e.g.: co-morbid conditions, extremes of age, socio-economic factors)

Acupuncture Treatment Service: The Acupuncture service includes a brief assessment of the patient’s

condition, as well as documentation of the patient’s response to the treatment. A reevaluation (an Established

Patient E/M service) is indicated when services above and beyond the usual pre-service and post-service work

associated with the acupuncture services is required. This may include circumstances where there are new

clinical findings, a rapid change in the individual's status, or failure to respond to treatment interventions.

The E/M services may include all or some of the components of the initial evaluation, such as:

• Data collection with objective measurements taken based on appropriate and relevant assessment tests

and tools using comparable and consistent methods;

• Clinical decision-making as to whether acupuncture care is still indicated;

• Organizing the composite of current health conditions and deciding a priority/focus of treatment;

• Identifying the appropriate intervention(s) for new or ongoing goal achievement;

• Modification of intervention(s);

• Revision in plan of care if needed;

• Evaluation of any meaningful changes in function;

• Deciphering effectiveness of intervention(s); and

• Updating the discharge plan as appropriate.

Standardized Tests and Measures/Functional Outcome Measures (FOMs): Measuring outcomes is an

important component of an acupuncturist’s practice. Outcome measures are important in direct management of

individual patient care and for the opportunity they provide the profession in collectively comparing care and

determining effectiveness.

The use of standardized tests and measures early in an episode of care establishes the baseline status of the

patient, providing a means to quantify change in the patient's functioning. Outcome measures, along with other

standardized tests and measures used throughout the episode of care provide information about whether

predicted outcomes are being realized. As the patient reaches the termination of acupuncture services and the

end of the episode of care, the acupuncturist, again, measures the outcomes of their services. Standardized

outcome measures provide a common language with which to evaluate the success of interventions, thereby

providing a basis for comparing outcomes related to different intervention approaches. Measuring outcomes of

care within the relevant components of function (including body functions and structures), activity, and

participation, among patients with the same diagnosis, is the foundation for determining which intervention

approaches comprise best clinical practice.

LITERATURE REVIEW

Acupuncture: The clinical utility of acupuncture is widely debated. Evaluating the clinical efficacy of

acupuncture in the context of clinical trials is challenging primarily because of the difficulty of designing

randomized trials with appropriate blinding of both subjects and providers. Many studies lack appropriate

controls, adequate study size, randomization and/or consistent outcome measures.

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Study controls for comparing real acupuncture (also referred to as verum acupuncture) typically include a

placebo, sham acupuncture, standard treatment, or no treatment. Sham acupuncture is the most often used

control in studies evaluating the efficacy of acupuncture. However, there is no standardized method for

employing sham acupuncture and no consensus on needle placement, making it difficult to generalize findings

across studies. The goal of applying sham acupuncture is to refrain from stimulating acupuncture points. In

many studies, sham is done at irrelevant acupuncture sites; however, evidence has shown sham acupuncture

evokes physiological responses. Because the evidence suggests that sham acupuncture is not truly a

physiologically neutral event, its use as a control in clinical trials is debatable. It is difficult to distinguish between

the specific effects of treatment versus that of the placebo. It has been reported that the ratio of improvement in

sham groups was substantially higher than in truly inert placebo groups (Madsen, et al., 2009; Ezzo, et al.,

2000). Although initially believed to have no effect, some researchers contend that needle placement in any

position invokes a biological response that may interfere with the interpretation of findings.

There are now several thousand RCTs evaluating the effectiveness of acupuncture for hundreds of different

conditions. The literature is examined below.

Chronic Pain: Vickers et al. conducted a meta-analysis of trials of acupuncture for chronic pain (Vickers et al.,

2012). Eligible trials included those for mechanical low back and neck pain, shoulder pain, headache and

osteoarthritis. Study subjects were required to have had pain for a minimum of four weeks and be followed for at

least four weeks after the end of treatment. There were no restrictions on what outcomes measures could be

used. The analysis identified 29 trials that met these criteria with a total of 17,922 individual patients analyzed.

The analysis found acupuncture to be superior to both sham and no acupuncture control for each of the four

conditions studied (all p<0.001). The effect sizes were similar across all pain conditions. Patients receiving

acupuncture had less pain, with scores 0.23 and 0.15 standard deviations lower than sham controls for back

and neck pain, osteoarthritis, and chronic headache respectively; the effect sizes in comparison to no

acupuncture controls were 0.55, 0.57 and 0.42. It is worth noting that the differences between acupuncture and

sham are quite modest when compared to the differences between acupuncture and no acupuncture. Sensitivity

analyses including for publication bias did not change these findings. The authors concluded, “Our results from

individual patient data meta-analyses of nearly 18,000 randomized patients on high quality trials provide the

most robust evidence to date that acupuncture is a reasonable referral option for patients with chronic pain.”

National Institute for Health and Care Excellence (NICE) guideline (2021) examined the literature on

acupuncture and chronic pain. Findings included the following:

• Acupuncture versus sham acupuncture

 Pain reduction

 Very low quality evidence from 13 studies with 1230 participants showed a clinically

important benefit of acupuncture compared to sham acupuncture at ≤3 months.

 Low quality evidence from 2 studies with 159 participants showed a clinically important

benefit of acupuncture compared to sham acupuncture at ≤3 months.

 Low quality evidence from 4 studies with 376 participants showed no clinically important

difference between acupuncture and sham acupuncture at >3 months.

 Moderate quality evidence from 2 studies with 159 participants showed a clinically

important benefit of acupuncture compared to sham acupuncture at >3 months.

 Low quality evidence from 1 study with 61 participants showed no clinically important

difference between acupuncture and sham acupuncture at >3 months

 Quality of life

 Low to moderate quality evidence from 2 studies with 210 participants showed a

clinically important benefit of acupuncture compared to sham acupuncture at ≤3

months.

 Moderate quality evidence from 1 study with 158 participants showed sham

acupuncture to have a clinically important improvement compared to acupuncture at ≤3

months.

 Very low quality evidence from 3 studies with 244 participants showed no clinically

important difference between acupuncture and sham acupuncture at ≤3 months.

 Very low quality evidence from 2 studies with 168 participants showed a clinically

important benefit of acupuncture compared to sham acupuncture at ≤3 months.

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 Very low to low quality evidence from 1 study with 178 participants showed a clinically

important benefit, clinically important harm and no clinically important difference of

acupuncture compared to sham acupuncture at ≤3 months (various quality of life

subscales).

 Moderate quality evidence from 2 studies with 159 participants showed a clinically

important benefit of acupuncture compared to sham acupuncture at ≤3 months.

 Low quality evidence from 1 study with 72 participants showed a clinically important

benefit of acupuncture compared to sham acupuncture at ≤3 months.

 Very low quality evidence from 1 study with 76 participants showed a clinically

important benefit of sham acupuncture compared to verum acupuncture at >3 months.

 Low quality evidence from 1 study with 96 participants showed no clinically important

difference between acupuncture and sham acupuncture at >3 months.

 Low quality evidence from 1 study with 153 participants showed a clinically important

benefit of acupuncture compared to sham acupuncture at >3 months.

 Moderate quality evidence from 1 study with 159 participants showed a clinically

important benefit of acupuncture compared to sham acupuncture at >3 months.

 Physical function

 Very low quality evidence from 1 study with 118 participants showed no clinically

important difference between acupuncture and sham acupuncture at ≤3 months.

 Very low quality evidence from 1 study with 106 participants showed no clinically

important difference between acupuncture and sham acupuncture at >3 months.

• Acupuncture versus usual care

 Pain reduction

 Low quality evidence from 5 studies with 234 participants showed a clinically important

benefit of acupuncture compared to usual care at ≤3 months. Low quality evidence from

2 studies with 384 participants showed no clinically important difference between

acupuncture and usual care at ≤3 months.

 Moderate quality evidence from 1 study with 3162 participants showed a clinically

important benefit of acupuncture compared to usual care at ≤3 months.

 Moderate quality evidence from 1 study with 344 participants showed no clinically

important difference between acupuncture and usual care at >3 months.

 Quality of life

 Moderate quality evidence from 1 study with 3213 participants showed a clinically

important benefit of acupuncture compared to usual care at ≤3 months. Very low quality

evidence from 1 study with 100 participants showed both a clinically important benefit

and no clinically important difference between acupuncture and usual care at ≤3

months (various quality of life subscales).

 Low quality evidence from 1 study with 204 participants showed a clinically important

benefit of acupuncture compared to usual care at >3 months.

 Physical function

 Very low quality evidence from 1 study with 45 participants showed no clinically

important difference between acupuncture and usual care at ≤3 months.

 Very low quality evidence from 1 study with 100 participants showed a clinically

important benefit of acupuncture compared to usual care at ≤3 months.

 Pain self-efficacy

 Very low quality evidence from 1 study with 294 participants showed a clinically

important benefit of acupuncture compared to usual care at ≤3 months.

 Pain interference

 Very low quality evidence from 1 study with 100 participants showed a clinically

important benefit of acupuncture compared to usual care at >3 months.

Nielsen et al. (2022) updated the evidence base for acupuncture therapy for acute pain with a review of

systematic reviews and meta-analyses on postsurgical/perioperative pain with opioid sparing and acute

nonsurgical/trauma pain, including acute pain in the emergency department. There are 22 systematic reviews,

17 with meta-analyses of acupuncture in acute pain settings, and a review for acute pain in the intensive care

unit. There are additional studies of acupuncture in acute pain settings. The majority of reviews found

acupuncture therapy to be an efficacious strategy for acute pain, with potential to avoid or reduce opioid

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reliance. Future multicenter trials are needed to clarify the dosage and generalizability of acupuncture for acute

pain in the emergency department. With an extremely low risk profile, acupuncture therapy is an important

strategy in comprehensive acute pain care.

Osteoarthritis: A Cochrane Review of acupuncture for peripheral joint arthritis identified sixteen trials (3498

individual patients) of adequate quality for review (Manheimer et al., 2010). Twelve of these trials included only

people with OA of the knee, three were for OA of the hip and one trial included both hip and knee. Acupuncture

showed statistically significant, short term improvements in OA pain and function. However these differences

were not considered to be clinically significant. Using only studies with sham controls deemed adequate to blind

participants, these differences were small and not statistically significant. On a pain scale of 0-20, these

differences were in the range of 3-4 points. On a functional scale of 0-68, improvements ranged from 3 to 11

points. However, greater effects were seen when compared to waiting list controls. The overall conclusion was

that at both 8 and 26 week end points, acupuncture offered small benefits in pain and function. These benefits

were deemed to be at least partially due to non-specific treatment effects. Atalay et al. (2021) sought to

determine the effect of acupuncture treatment and physiotherapy on pain, physical function, and quality of life

(QOL) in patients with knee osteoarthritis (KOA). One hundred patients with KOA were randomly divided into the

acupuncture group and the physiotherapy group. Both treatments were given in 12 sessions over 6 weeks.

Thirteen acupuncture points were selected for the knee. Local points were GB34, SP10, SP9, ST36, ST35,

ST34, EX-LE2, EX-LE5, EXLE4, and distal (distant) points were defined as KI3, SP6, LI4, and ST41. The Visual

Analog Scale (VAS) was used to measure pain intensity. The Western Ontario and McMaster Universities

Osteoarthritis Index (WOMAC) and the 36-Item Short Form Health Survey (SF-36) were used to determine

functional status and health-related QOL, respectively. All patients were evaluated at baseline, after the last

treatment, and at the 12-week follow-up period. There was no statistically significant difference between the

acupuncture group and physiotherapy group in terms of pain, total WOMAC, and SF-36 levels at baseline, after

treatment, and at the 12th week after treatment (P > 0.05). Both treatments significantly improved functional

status and decreased the level of pain assessed by VAS at the 12-week follow-up of the study. There was no

adverse advent related to therapeutic methods. Authors concluded that the acupuncture and physiotherapy

performed twice weekly for 6 weeks have similar effects with regard to pain, functional status, and QOL. There

were no significant differences between the acupuncture and physiotherapy groups in relief of pain, improved

functional status, and QOL in the treatment of KOA. Both acupuncture and physiotherapy treatments were found

to yield significantly superior results when compared with baseline values.

Tian et al. (2022) evaluated the efficacy of acupuncture for knee OA (KOA) patients and calculate the required

information size (RIS) to determine whether further clinical studies are required. Eleven RCTs with 2484 patients

were included in our meta-analysis, meeting the inclusion criteria for the meta-analysis. The meta-analysis

indicated that acupuncture had a beneficial effect on knee osteoarthritis in reducing pain and improving patient’s

functional activities, but true acupuncture showed no significant effect in relief of patient's stiffness. No

significant difference in improving the quality life of mental and physical health compared with sham

acupuncture was found. Authors concluded that acupuncture has a beneficial effect on pain relief and improves

functional activities, and this treatment can be recommended as a beneficial alternative therapy in patients with

KOA, particularly for chronic patients and those currently undergoing long-term pain, and help them to increase

their quality of life.

Lin et al. (2022) systematically evaluated the efficacy and safety effectiveness of acupuncture inactivation of

myofascial pain trigger points in the treatment of osteoarthritis of the knee. A total of 724 patients from 9 RCTs

were finally included, and the results of meta-analysis showed that the acupuncture myofascial pain trigger point

group was better than the control group in terms of total effective rate, cure rate, VAS score, Lysholm score, and

WOMAC score. Authors concluded that the efficacy and safety of acupuncturing myofascial pain trigger points in

the treatment of knee osteoarthritis is positive, but due to the limited number of literature included in this study

and the low quality of the included literature, there is still a need for high-quality and large sample size RCTs for

the analysis of this treatment option.

Headache: Linde et al. conducted a Cochrane Review of acupuncture for tension-type headaches (Linde et al.,

2009). Eleven trials with 2317 subjects met the inclusion criteria. Two of the trials compared acupuncture to

routine care (including self-care) and found clinically and statistically significant benefits to acupuncture for both

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headache frequency and pain intensity. In these two trials 47% of patients receiving acupuncture reported a

decrease in the number of headache days by at least 50%, compared to 16% of patients in the control groups.

Six of the trials compared acupuncture to some form of sham acupuncture where needle placement was not

guided by any specific acupuncture findings. In this comparison, 50% of the “true” acupuncture patients

experienced a greater than 50% reduction in headache pain compared to 41% in the sham controls. Three trials

compared acupuncture to massage, physiotherapy, or relaxation. The methodological quality of these studies

was poor and the results difficult to interpret, but overall there appeared to be a slight benefit to acupuncture

compared to these interventions. A previous Cochrane review of this topic yielded inconclusive results.

However, the addition of six newer trials in this review led the authors to conclude that acupuncture could be “a

valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.”

Another Cochrane Review examined acupuncture for migraine headache prophylaxis (Linde et al., 2009).

Twenty-two trials with 4419 participants met the inclusion criteria. Six of the trials compared acupuncture to no

treatment or routine care. The acupuncture care resulted in fewer headaches than in the controls over 3-4

months. One of the trials followed patients for nine months and the treatment effects were undiminished.

Fourteen trials compared acupuncture to some form of sham intervention. The results of single trials varied

considerably, but the pooled results did not show any clinically or statistically significant benefit to the “true”

acupuncture. Four trials compared acupuncture to drug prophylaxis and demonstrated slightly better outcomes

and fewer side effects in the acupuncture groups. Overall the authors conclude that acupuncture should be

considered a valid treatment option for migraine prophylaxis.

Turkistani et al. (2021) evaluated the effectiveness of acupuncture and manual therapy in tension-type

headaches. Eight articles involving 3846 participants showed evidence that acupuncture and manual therapy

can be valuable non-pharmacological treatment options for tension-type headaches. Acupuncture was

compared to routine care or sham intervention. Acupuncture was not found to be superior to physiotherapy,

exercise, and massage therapy. Randomized controlled trials done in various countries showed manual therapy

also significantly decreased headache intensity. Manual therapy has an efficacy that equals prophylactic

medication and tricyclic antidepressants in treating tension-type headaches. The available data suggests that

both acupuncture and manual therapy have beneficial effects on treating symptoms of tension-type headache.

However, further clinical trials looking at long-term benefits and risks are needed.

Zheng et al. (2022) examined the effectiveness of acupuncture with a follow-up period of 32 weeks. They

conducted a randomized controlled trial, and 218 participants who were diagnosed with chronic tension-type

headache (CTTH). The participants in the intervention group received 20 sessions of true acupuncture (TA

group) over 8 weeks. The acupuncture treatments were standardized across participants, and each acupuncture

site was needled to achieve deqi sensation. Each treatment session lasted 30 minutes. The participants in the

control group received the same sessions and treatment frequency of superficial acupuncture (SA group)-

defined as a type of sham control by avoiding deqi sensation at each acupuncture site. A responder was defined

as a participant who reported at least a 50% reduction in the monthly number of headache days (MHDs). The

responder rate was 68.2% in the TA group (n=110) versus 48.1% in the SA group (n=108) at week 16; and it

was 68.2% in the TA group versus 50% in the SA group at week 32. The reduction in MHDs was 13.1±9.8 days

in the TA group versus 8.8±9.6 days in the SA group at week 16, and the reduction was 14±10.5 days in the TA

group versus 9.5±9.3 days in the SA group at week 32. Four mild adverse events were reported; three in the TA

group versus one in the SA group. Authors concluded that the 8-week TA treatment was effective for the

prophylaxis of CTTH. Further studies might focus on the cost-effectiveness of the treatment.

Low Back and Neck Pain: Liu et al. examined the set of systematic reviews of acupuncture for low back pain

(Liu et al., 2015). They identified 16 systematic reviews, the overall quality of which they judged to be low. They

found inconclusive evidence of a benefit for acupuncture compared to a sham for acute low back pain. For

chronic low back pain there was consistent evidence of a benefit for short term pain relief and functional

improvement when compared to sham or to no treatment. This benefit was found both when acupuncture was

used in isolation and when used as an adjunct treatment.

In another AHRQ publication by Chou et al. (2016) titled Noninvasive Treatments for Low Back Pain, noted the

following key points:

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• For acute low back pain, a systematic review found acupuncture associated with lower pain intensity

versus sham acupuncture using nonpenetrating needles; three other trials reported effects consistent

with these findings. One trial of sham acupuncture using penetrating needles to nonacupuncture points

found no effect on pain. These were no clear effects on function in 5 trials (Strength of Evidence (SOE):

low for pain and function).

• For chronic low back pain, a systematic review found acupuncture associated with lower pain intensity

versus sham acupuncture (superficial needling at acupuncture or nonacupuncture points, or

nonpenetrating pressure at acupuncture points) immediately at the end of treatment and at up to 12

weeks, but there were no differences in function. Four additional trials reported results consistent with

these findings (SOE: moderate for pain and function).

• For chronic low back pain, a systematic review found acupuncture associated with lower pain intensity

and better function immediately after treatment versus no acupuncture. Mean effects on pain ranged

from 7 to 24 points on a 0- to 100-point scale; for function one trial reported a difference of 8 points on a

0- to 100-point scale and the other two trials; two trials showed small or no clear differences at longer-

term follow-up (SOE: moderate for pain and function).

• For acute low back pain, a systematic review found acupuncture associated with slightly greater

likelihood of overall improvement versus NSAIDs at the end of treatment (SOE: low).

• For chronic low back pain, a systematic review found acupuncture associated with better pain relief and

improvement in function immediately postintervention (SOE: low).

• Harms of acupuncture were poorly reported in the trials, though no serious adverse events were

reported (SOE: low).

Qaseem et al. (2017) provided clinical recommendations on noninvasive treatment of low back pain:

Recommendation 1: Given that most patients with acute or subacute low back pain improve over time

regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat

(moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). (Grade:

strong recommendation). Recommendation 2: For patients with chronic low back pain, clinicians and patients

should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture,

mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise,

progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive

behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).

Chou et al. (2017) updated the 2007 American College of Physicians guideline that addressed

nonpharmacologic treatment options for low back pain. New evidence was available. Authors systematically

reviewed the current evidence on nonpharmacologic therapies for acute or chronic non radicular or radicular low

back pain. Randomized trials of 9 nonpharmacologic options versus sham treatment, wait list, or usual care, or

of 1 nonpharmacologic option versus another were included. New evidence indicated that tai chi (strength of

evidence [SOE], low) and mindfulness-based stress reduction (SOE, moderate) are effective for chronic low

back pain and strengthens previous findings regarding the effectiveness of yoga (SOE, moderate). Evidence

continues to support the effectiveness of exercise, psychological therapies, multidisciplinary rehabilitation, spinal

manipulation, massage, and acupuncture for chronic low back pain (SOE, low to moderate). Limited evidence

shows that acupuncture is modestly effective for acute low back pain (SOE, low). The magnitude of pain

benefits was small to moderate and generally short term; effects on function generally were smaller than effects

on pain.

Wong et al. (2017) authored a systematic review for the Ontario Protocol for Traffic Injury Management

(OPTIMa) Collaboration. According to high-quality guidelines: (1) all patients with acute or chronic LBP should

receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should

be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs

(NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or

NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological

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treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation.

According to Tice et al. (2017), the strength of evidence appears adequate to support coverage of acupuncture,

CBT, MBSR, and yoga for chronic low back pain. Evidence-based boundaries on duration of therapy and on

repetitive courses of therapy are reasonable given the potential for inappropriate overuse of services. Authors

reported that there was no evidence on the concurrent use of multiple modalities, so concurrent treatment

should be treated on a case-by-case basis.

Xiang et al. (2017) sought to establish whether sham acupuncture (SA) or placebo acupuncture (PA) was more

efficacious for reducing low back pain (LBP) than other routine treatments and to discuss whether SA or PA is

appropriate for randomized controlled trials of acupuncture for LBP. Review identified 7 trials (1768

participants); all were included in the meta-analysis. They found statistically significant differences in pain

reduction post-intervention between SA or PA and routine care or a waiting list, however, no significant

difference was observed between SA or PA and routine care or no treatment for post-intervention function.

Authors concluded that compared with routine care or a waiting list, SA or PA was more efficacious for pain

relief post-intervention. Concluding that SA or PA is appropriate for acupuncture research would be premature.

Guidelines evaluating SA or PA control methods are needed to determine the specific effect of acupuncture over

placebo.

Mu et al. (2020) authored an updated Cochrane review. This review is a split from an earlier Cochrane review

and it focuses on chronic LBP. Mu et al. (2020) assessed the effects of acupuncture compared to sham

intervention, no treatment, or usual care for chronic nonspecific LBP. Authors included only randomized

controlled trials (RCTs) of acupuncture for chronic nonspecific LBP in adults. They excluded RCTs that

investigated LBP with a specific etiology. Trials comparing acupuncture with sham intervention, no treatment,

and usual care were included. The primary outcomes were pain, back-specific functional status, and quality of

life; the secondary outcomes were pain-related disability, global assessment, or adverse events. Authors

included 33 studies (37 articles) with 8270 participants. The majority of studies were carried out in Europe, Asia,

North and South America. Seven studies (5572 participants) conducted in Germany accounted for 67% of the

participants. Sixteen trials compared acupuncture with sham intervention, usual care, or no treatment. Most

studies had high risk of performance bias due to lack of blinding of the acupuncturist. A few studies were found

to have high risk of detection, attrition, reporting or selection bias. Mu et al. (2020) found low-certainty evidence

(seven trials, 1403 participants) that acupuncture may relieve pain in the immediate term (up to seven days)

compared to sham intervention, visual analogue scale (VAS) 0-100). The difference did not meet the clinically

important threshold of 15 points or 30% relative change. Very low-certainty evidence from five trials (1481

participants) showed that acupuncture was not more effective than sham in improving back-specific function in

the immediate term; corresponding to the Hannover Function Ability Questionnaire (HFAQ, 0 to 100, higher

values better) change. Three trials (1068 participants) yielded low-certainty evidence that acupuncture seemed

not to be more effective clinically in the short term for quality of life; corresponding to the physical 12-item Short

Form Health Survey (SF-12, 0-100, higher values better) change. The reasons for downgrading the certainty of

the evidence to either low to very low were risk of bias, inconsistency, and imprecision. We found moderate-

certainty evidence that acupuncture produced greater and clinically important pain relief; (VAS, 0 to 100), and

improved back function; five trials, 2960 participants; corresponding to the HFAQ change in the immediate term

compared to no treatment. The evidence was downgraded to moderate certainty due to risk of bias. No studies

reported on quality of life in the short term or adverse events. Low-certainty evidence (five trials, 1054

participants) suggested that acupuncture may reduce pain; not clinically important on 0 to 100 VAS), and

improve back-specific function immediately after treatment; five trials, 1381 participants; corresponding to the

HFAQ change compared to usual care. Moderate-certainty evidence from one trial (731 participants) found that

acupuncture was more effective in improving physical quality of life but not mental quality of life in the short

term. The certainty of evidence was downgraded to moderate to low because of risk of bias, inconsistency, and

imprecision. Low-certainty evidence suggested a similar incidence of adverse events immediately after

treatment in the acupuncture and sham intervention groups (four trials, 465 participants), and the acupuncture

and usual care groups (one trial, 74 participants). The certainty of the evidence was downgraded due to risk of

bias and imprecision. No trial reported adverse events for acupuncture when compared to no treatment. The

most commonly reported adverse events in the acupuncture groups were insertion point pain, bruising,

hematoma, bleeding, worsening of LBP, and pain other than LBP (pain in leg and shoulder). Authors concluded

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that acupuncture may not play a more clinically meaningful role than sham in relieving pain immediately after

treatment or in improving quality of life in the short term, and acupuncture possibly did not improve back function

compared to sham in the immediate term. However, acupuncture was more effective than no treatment in

improving pain and function in the immediate term. Trials with usual care as the control showed acupuncture

may not reduce pain clinically, but the therapy may improve function immediately after sessions as well as

physical but not mental quality of life in the short term. The evidence was downgraded to moderate to very low-

certainty considering most of studies had high risk of bias, inconsistency, and small sample size introducing

imprecision. The decision to use acupuncture to treat chronic low back pain might depend on the availability,

cost and patient’s preferences.

Su et al. (2021) critically evaluated the evidence for acupuncture as an effective treatment for acute LBP

(ALBP). Of the 13 eligible RCTs identified, 11 RCTs (involving 707 patients) provided moderate-quality evidence

that acupuncture has a statistically significant association with improvements in VAS (visual analog scale) score.

Two studies indicated that acupuncture did not influence the RMDQ (Roland-Morris Disability Questionnaire)

scores more than the control treatment. Three studies suggested that acupuncture influenced the ODI

(Oswestry Disability Index) scores more than the control treatment. Two studies suggested that acupuncture

influenced the number of medication taken more than the control treatment. Authors conclude that acupuncture

treatment of acute LBP was associated with modest improvements in the VAS score, ODI score, and the

number of pills, but not the RMDQ score. However findings should be considered with caution due to the low

power original studies. High-quality trials are needed to assess further the role of acupuncture in the treatment

of acute LBP.

Wu et al. (2021) evaluated and compared the efficacy and safety of different acupuncture therapies for ALBP. In

total, nineteen randomized controlled trials (RCTs) comprising 1,427 participants were included. Results showed

the following: (I) compared with placebo, motion style acupuncture (MSA), manual acupuncture (MA), and

electroacupuncture (EA) were found to be more effective for decreasing VAS score; (II) compared with

pharmacotherapy, MSA and MA were found to be more effective in reducing ROM score. Results of the surface

under the cumulative ranking curve indicated that all acupuncture types were superior to placebo or

pharmacotherapy in lowering VAS and ROM score. It was noted that MSA was the most effective treatment.

Authors concluded that this study indicated that acupuncture therapy achieved good therapeutic effects in the

treatment of ALBP, especially MSA therapy. Nevertheless, due to the low quality of the included trials, the

credibility of conclusions is low. Further well-designed RCTs with high quality and large samples are still needed

to evaluate the efficacy and safety of acupuncture therapy for ALBP.

Huang et al. (2021) investigated the effect and safety of acupuncture for the treatment of chronic spinal pain.

Data was extracted from 22 RCTs including 2588 patients. Pooled analysis revealed that acupuncture can

reduce chronic spinal pain compared to sham acupuncture), mediation control, usual care control, and no

treatment control. In terms of functional disability, acupuncture can improve physical function at immediate-term

follow-up, short-term follow-up, and long-term follow-up. In summary, compared to no treatment, sham

acupuncture, or conventional therapy such as medication, massage, and physical exercise, acupuncture has a

significantly superior effect on the reduction in chronic spinal pain and function improvement. Acupuncture might

be an effective treatment for patients with chronic spinal pain and it is a safe therapy.

Baroncini et al. (2022) investigated the available randomized control trials (RCTs) to point out which

acupuncture protocol is the most effective for chronic aspecific low back pain (LBP). Efficacy was measured in

terms of pain (Visual Analogic Scale, VAS) and disability (Roland Morris Disability Questionnaire, RMQ),

Transcutaneous Electrical Nerve Stimulation (TENS). Data from 44 RCTs (8338 procedures) were retrieved.

56% of patients were women. The mean age of the patients was 48 ± 10.6 years. The mean BMI was 26.3 ± 2.2

kg/m2. Authors concluded that verum acupuncture is more effective than sham treatment for the non-

pharmacological management of LBP. Among the verum protocols, individualized acupuncture and standard

acupuncture with TENS were the protocols that resulted in the highest improvement in pain and quality of life.

Yang et al. (2022) investigated the effects of acupuncture on pain, functional status and quality of life for women

with (low back and/or pelvic pain) LBPP pain during the pregnancy. The primary outcomes were pain, functional

status and quality of life. The secondary outcomes were overall effects (a questionnaire at a post-treatment visit

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within a week after the last treatment to determine the number of people who received good or excellent help),

analgesic consumption, Apgar scores >7 at 5 min, adverse events, gestational age at birth, induction of labour

and mode of birth. This meta-analysis included 10 studies, reporting on a total of 1040 women. Overall,

acupuncture significantly relieved pain during pregnancy and improved functional status and quality of life.

There was a significant difference for overall effects. However, there was no significant difference for analgesic

consumption during the study period and Apgar scores of newborns. Preterm birth from acupuncture during the

study period was reported in two studies. Although preterm contractions were reported in two studies, all infants

were in good health at birth. Authors concluded that acupuncture significantly improved pain, functional status

and quality of life in women with LBPP during the pregnancy. Additionally, acupuncture had no observable

severe adverse influences on the newborns. More large-scale and well-designed RCTs are still needed to

further confirm these results.

Cancer Pain: A Cochrane Review by Paley et al. reviewed the trials of acupuncture for cancer pain in adults

(Paley et al., 2011). Three RCTs with 204 patients met the inclusion criteria. One study compared traditional

auricular acupuncture with auricular acupuncture at non-acupuncture points and with a control using non-

invasive “ear seeds,” at non-acupuncture points. The remaining two studies compared acupuncture with pain

medication. The reviewers concluded that while there was some evidence of acupuncture effectiveness there

was a high risk of bias in all studies and no conclusions could be reached regarding acupuncture effectiveness.

Paley et al. (2015) updated the Cochrane review. They found five studies (with a total of 285 participants) that

compared acupuncture against either sham acupuncture or pain-killing medicines. All five identified studies had

small sample sizes, which reduces the quality of their evidence. Authors reported that none of the studies

described in this review were big enough to produce reliable results. None of the studies reported any harm to

the participants. They concluded that there was insufficient evidence to judge whether acupuncture is eIective in

relieving cancer pain in adults and that larger, well-designed studies are needed to provide evidence in this

area.

Yang et al. (2021) analyzed currently available publications regarding the use of acupuncture for pain

management among patients with cancer in palliative care settings. Five studies (n=189) were included in this

systematic review. Results indicated a favourable effect of acupuncture on pain relief in palliative care for

patients with cancer. Authors concluded that acupuncture may be an effective and safe treatment associated

with pain reduction in the palliative care of patients with cancer. Further high-quality, adequately powered

studies are needed in the future.

Li et al. (2021) evaluated the effect of acupuncture on treatment-related symptoms among breast cancer

survivors. The primary outcomes were pain, hot flashes, sleep disturbance, fatigue, depression, lymphedema,

and neuropathy as individual symptoms. They also evaluated adverse events reported in acupuncture studies.

Of 26 selected trials (2055 patients), 20 (1709 patients) were included in the meta-analysis. Acupuncture was

more effective than control groups in improving pain intensity, fatigue, and hot flash severity. The subgroup

analysis indicated that acupuncture showed trends but not significant effects on all the treatment-related

symptoms compared with the sham acupuncture groups. Compared with waitlist control and usual care groups,

the acupuncture groups showed significant reductions in pain intensity, fatigue, depression, hot flash severity,

and neuropathy. No serious adverse events were reported related to acupuncture intervention. Mild adverse

events (i.e., bruising, pain, swelling, skin infection, hematoma, headache, menstrual bleeding) were reported in

11 studies. This systematic review and meta-analysis suggest that acupuncture significantly reduces multiple

treatment-related symptoms compared with the usual care or waitlist control group among breast cancer

survivors. The safety of acupuncture was inadequately reported in the included studies. Based on the available

data, acupuncture seems to be generally a safe treatment with some mild adverse events. These findings

provide evidence-based recommendations for incorporating acupuncture into clinical breast cancer symptom

management. Due to the high risk of bias and blinding issues in some RCTs, more rigorous trials are needed to

confirm the efficacy of acupuncture in reducing multiple treatment-related symptoms among breast cancer

survivors.

Zhang et al. (2021) evaluated the effects of acupuncture in women with breast cancer (BC), focusing on patient-

reported outcomes (PROs). Out of the 2, 524 identified studies, 29 studies representing 33 articles were

included in this meta-analysis. At the end of treatment (EOT), the acupuncture patients’ quality of life (QoL) was

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measured by the QLQ-C30 QoL subscale, the Functional Assessment of Cancer Therapy-Endocrine Symptoms

(FACT-ES), the Functional Assessment of Cancer Therapy-General/Breast (FACT-G/B), and the Menopause-

Specific Quality of Life Questionnaire (MENQOL), which depicted a significant improvement. The use of

acupuncture in BC patients lead to a considerable reduction in the scores of all subscales of the Brief Pain

Inventory-Short Form (BPI-SF) and Visual Analog Scale (VAS) measuring pain. Moreover, patients treated with

acupuncture were more likely to experience improvements in hot flashes scores, fatigue, sleep disturbance, and

anxiety compared to those in the control group, while the improvements in depression were comparable across

both groups. Long-term follow-up results were similar to the EOT results. Authors concluded that current

evidence suggests that acupuncture might improve BC treatment-related symptoms measured with PROs

including QoL, pain, fatigue, hot flashes, sleep disturbance and anxiety. However, a number of included studies

report limited amounts of certain subgroup settings, thus more rigorous, well-designed and larger RCTs are

needed to confirm our results.

Ge et al. (2022) developed an evidence-based clinical practice guideline of acupuncture in the treatment of

patients with moderate and severe cancer pain. Recommendations were developed through a Delphi consensus

of an international multidisciplinary panel including 13 western medicine oncologists, Chinese

medicine/acupuncture clinical practitioners, and two patient representatives. The certainty of evidence, patient

preferences and values, resources, and other factors were fully considered in formulating the recommendations.

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was

employed to rate the certainty of evidence and the strength of recommendations. The guideline proposed three

recommendations: (1) a strong recommendation for the treatment of acupuncture rather than no treatment to

relieve pain in patients with moderate to severe cancer pain; (2) a weak recommendation for the combination

treatments with acupuncture/acupressure to reduce pain intensity, decrease the opioid dose, and alleviate

opioid-related side effects in moderate to severe cancer pain patients who are using analgesics; and (3) a

strong recommendation for acupuncture in breast cancer patients to relieve their aromatase inhibitor-induced

arthralgia. This proposed guideline provides recommendations for the management of patients with cancer pain.

The small sample sizes of evidence limit the strength of the recommendations and highlights the need for

additional research.

Zhang et al. (2022) evaluated and summarized the systematic reviews (SRs) that assess the effects and safety

of acupuncture for cancer-related conditions, and to inform clinical practice and future studies. Fifty-one SRs of

RCTs on acupuncture for cancer-related conditions were included and synthesized. The methodological quality

of SRs included 1 "high", 5 "low" and 45 "very low" by AMSTAR 2. Acupuncture showed effectiveness on

systemic conditions in relation to different cancers, including cancer-related pain (17 SRs, 80 RCTs), fatigue (7

SRs, 18 RCTs), insomnia (4 SRs, 10 RCTs), quality of life (2 SRs, 15 RCTs); conditions in relation to chemo-

radiotherapy, including nausea and vomiting (3 SRs, 36 RCTs) and bone marrow suppression (2 SRs, 21

RCTs); and conditions in relation to specific cancers, including breast cancer-related menopause (3 SRs, 6

RCTs), hot flashes (12 SRs, 13 RCTs), arthralgia (5 SRs, 10 RCTs), and nasopharyngeal cancer-related

dysphagia (1 SRs, 7 RCTs). Acupuncture appeared to have benefit for patients with lymphoedema (3 SRs, 3

RCTs), gastrointestinal function (5 SRs, 27 RCTs), and xerostomia (4 SRs, 7 RCTs). Limited evidence showed

inconsistent results on acupuncture for chemotherapy-induced peripheral neuropathy (3 SRs, 6 RCTs),

depression and anxiety (3 SRs, 9 RCTs). Acupuncture was regarded as a safe therapy for cancer patients as no

severe adverse events related were reported. Authors concluded that evidence from SRs showed that

acupuncture is beneficial to cancer survivors with cancer-related pain, fatigue, insomnia, improved quality of life,

nausea and vomiting, bone marrow suppression, menopausal symptoms, arthralgia, and dysphagia, and may

also be potential for lymphoedema, gastrointestinal function, and xerostomia. For neuropathy, depression and

anxiety, acupuncture should be used as an option based on individual conditions. Acupuncture is relatively safe

without serious adverse events. More well-designed clinical trials of acupuncture are recommended on cancer-

related depression and anxiety, arthralgia, xerostomia, gastrointestinal dysfunction and dysphagia.

Abe et al. (2022) aimed to identify the current treatment options for pain and numbness in cancer survivors and

to evaluate their effects. Cancer survivors were defined as patients diagnosed with cancer who had completed

active cancer treatment, whose conditions were stable, and who had no evidence of recurrent or progressive

disease. A meta-analysis was conducted using the random-effects model to obtain the effect sizes of 7 types of

treatments: opioid therapy, nonopioid pharmacotherapy, interventional therapy, acupuncture,

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education/cognitive behavioral therapy (CBT), physical exercise, and alternative medicine. A total of 36 studies

involving 2,870 cancer survivors were included. Among them, 35 (n=2,813) were included in the meta-analysis

for pain. The analysis suggested that physical exercise, acupuncture, and alternative medicine could

significantly reduce pain. Nonopioid pharmacotherapy and education/CBT did not demonstrate significant

effects. No studies were identified that investigated the effects of opioid therapy or interventional therapy on

pain. Regarding numbness, 5 studies (n=566) were included in the meta-analysis. Acupuncture (n=99; 2

studies) did not demonstrate significant effects on numbness, and the effects of nonopioid pharmacotherapy,

education/CBT, and physical exercise could not be determined due to the small number of included studies. No

studies were identified that investigated the effects of opioid therapy, interventional therapy, or alternative

medicine on numbness. Authors concluded that this meta-analysis suggested that physical exercise,

acupuncture, and alternative medicine may reduce pain in cancer survivors, with a very small to moderate

amount of evidence.

Mao et al. (2022) authored a joint guideline to provide evidence-based recommendations to practicing

physicians and other health care providers on integrative approaches to managing pain in patients with cancer.

The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical

oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine,

nursing, and patient advocacy representatives. The literature search included systematic reviews, meta-

analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included

pain intensity, symptom relief, and adverse events. Expert panel members used this evidence and informal

consensus to develop evidence-based guideline recommendations. The literature search identified 227 relevant

studies to inform the evidence base for this guideline. Recommendations included the following:

• Among adult patients, acupuncture should be recommended for aromatase inhibitor-related joint pain.

• Acupuncture or reflexology or acupressure may be recommended for general cancer pain or

musculoskeletal pain.

These recommendations are based on an intermediate level of evidence, benefit outweighing risk, and with

moderate strength of recommendation. There is insufficient or inconclusive evidence to make recommendations

for pediatric patients.

Hershman et al. (2022) examined the effect of acupuncture in reducing AI-related joint pain through 52 weeks. A

randomized clinical trial was conducted at 11 sites in the US from May 1, 2012, to February 29, 2016, with a

scheduled final date of follow-up of September 5, 2017, to compare true acupuncture (TA) with sham

acupuncture (SA) or waiting list control (WC). Participants were randomized 2:1:1 to the TA (n = 110), SA (n =

59), or WC (n = 57) group. The TA and SA protocols were composed of 6 weeks of intervention at 2 sessions

per week (12 sessions overall), followed by 6 additional weeks of intervention with 1 session per week.

Participants randomized to WC received no intervention. All participants were offered 10 acupuncture sessions

to be used between weeks 24 and 52. Among 226 randomized, 191 (84.5%) completed the trial. In this

randomized clinical trial, women with AI-related joint pain receiving 12 weeks of TA had reduced pain at 52

weeks compared with controls, suggesting long-term benefits of this therapy.

Neuropathic Pain: Ju et al. (2017) assessed the analgesic efficacy and adverse events of acupuncture

treatments for chronic neuropathic pain in adults. Randomized controlled trials (RCTs) with treatment duration of

eight weeks or longer comparing acupuncture (either given alone or in combination with other therapies) with

sham acupuncture, other active therapies, or treatment as usual, for neuropathic pain in adults were included in

this review. The primary outcomes were pain intensity and pain relief. The secondary outcomes were any pain-

related outcome indicating some improvement, withdrawals, participants experiencing any adverse event,

serious adverse events and quality of life. Authors included six studies involving 462 participants with chronic

peripheral neuropathic pain (442 completers (251 male), mean ages 52 to 63 years). Most studies included a

small sample size (fewer than 50 participants per treatment arm) and all studies were at high risk of bias for

blinding of participants and personnel. Authors concluded that due to the limited data available, there was

insufficient evidence to support or refute the use of acupuncture for neuropathic pain in general, or for any

specific neuropathic pain condition when compared with sham acupuncture or other active therapies. Yu et al.

(2021) evaluated the clinical efficacy of acupuncture through a review and analysis of systematic reviews of

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acupuncture for the treatment of diabetic peripheral neuropathy. Eighty eight reviews were retrieved. The

inclusion criteria were a published systematic evaluation/meta-analysis/systematic review of acupuncture

treatment for diabetic peripheral neuropathy, which included subjects meeting the diagnostic criteria for diabetic

peripheral neuropathy, and which compared acupuncture treatment with non-acupuncture treatment. After the

inclusion criteria had been applied, 18 reviews were finally included. Authors report that evidence shows that

acupuncture improves diabetic peripheral neuropathy and increases nerve conduction velocity. However, the

methodological quality of the reviews is generally extremely low, and most of the reviews had certain defects,

showing that there is still much room for improvement in terms of the methodology and quality of the research

reports.

Ben-Arye et al. (2022) explored the impact of acupuncture with other complementary and integrative medicine

(CIM) modalities on chemotherapy-induced peripheral neuropathy (CIPN) and quality of life (QoL) in oncology

patients. In this prospective, pragmatic, and patient-preference study, patients with CIPN were treated with

acupuncture and CIM therapies (intervention group) or standard care alone (controls) for 6 weeks. Patients in

the intervention arm were randomized to twice-weekly acupuncture-only (group A) or acupuncture with

additional manual-movement or mind-body CIM therapies (group B). Severity of CIPN was assessed with

various outcome measures. Of 168 participants, 136 underwent the study intervention (group A, 69; group B,

67), with 32 controls. Baseline-to-6-week assessment scores improved significantly in the intervention arm (vs

controls) on FACT-Tax and emotional well-being scores; FACT-TAX scores for hand numbness/tingling and

discomfort; and EORTC physical functioning. Intervention groups A and B showed improved FACT-Tax physical

well-being, FACT-TAX total score, FACT-TAX feet discomfort, and EORTC pain scores. Authors concluded that

acupuncture, with or without CIM modalities, can relieve CIPN-related symptoms during oncology treatment.

This is most pronounced for hand numbness, tingling, pain, discomfort, and for physical functioning.

Musculoskeletal and Pain Disorders of the Extremities: Cox et al. (2016) assessed the effectiveness and

safety of acupuncture therapies for musculoskeletal disorders of the extremities. The search revealed 5180

articles; 15 were included (10 with a low risk of bias, 5 with a high risk of bias). Authors concluded that the

evidence for the effectiveness of acupuncture for musculoskeletal disorders of the extremities was inconsistent.

Traditional needle acupuncture may be beneficial for CTS and Achilles tendinopathy, but not for nonspecific

upper extremity pain and patellofemoral syndrome. Electroacupuncture may be effective for shoulder injuries

and may show similar effectiveness to that of night wrist splinting for CTS. The effectiveness of dry needling for

plantar fasciitis is equivocal. Leggit (2018) summarized the consensus on acupuncture as a musculoskeletal

therapy. Evidence regarding efficacy in the management of musculoskeletal conditions is heterogeneous and

subject to several limitations. Despite these limitations, acupuncture consistently has been shown to be more

effective than no treatment and is relatively safe. For chronic back pain, it is recommended as a first-line

noninvasive therapy. For neck pain, acupuncture provides benefits when it is combined with other treatments.

Babatunde et al. (2021) evaluated the comparative effectiveness of treatment options for relieving pain and

improving function in patients with subacromial shoulder conditions (SSCs). The review identified 177 eligible

trials. Current evidence shows small to moderate effect sizes for most treatment options for SSCs. Six

treatments had a high probability of being most effective, in the short term, for pain and function [acupuncture,

manual therapy, exercise, exercise plus manual therapy, laser therapy and Microcurrent (MENS) (TENS)], but

with low certainty for most treatment options. After accounting for risk of bias, there is evidence of moderate

certainty for the comparative effects of exercise on function in patients with SSCs. Future large, high-quality

pragmatic randomized trials or meta-analyses are needed to better understand whether specific subgroups of

patients respond better to some treatments than others.

Fredy et al. (2022) described the role of acupuncture for myofascial pain syndrome (MPS) in interventional pain

management. They summarized that acupuncture, combined with other therapies, is effective in reducing pain

and improving physical function. Acupuncture can enhance endogenous opioids such as endorphins to relieve

pain and enhance the healing process. Authors concluded that acupuncture could be considered as one of

nonpharmacological options in Interventional Pain Management for MPS. Interventions with acupuncture are

safe and have minimal side effects when performed by a trained and competent practitioner.

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Nausea and Vomiting: A 2009 Cochrane Review (Lee and Fan, 2009) evaluated studies of the stimulation of

wrist acupuncture point P6 for the prevention of postoperative nausea and vomiting. Forty trials were identified

with 4858 individual subjects. Overall, acupuncture was found to be equally effective as anti-emetic drugs. This

was true for both adults and children. It was also found equally effective whether using invasive needles or non-

invasive stimulation of the acupuncture point.

Zhang et al. performed a meta-analysis (Zhang et al., 2015) on the use of wristband at acupuncture points for

postoperative nausea and vomiting. They found a significant reduction in post-operative vomiting through the

use of the wrist band compared to controls. However, they found no difference in the rates of nausea between

wrist band and control.

Lu et al. (2021) explored acupuncture’s clinical efficacy in treating hyperemesis gravidarum HG. A total of 16

trials covering 1043 gravidas were included. Compared with the conventional treatment, acupuncture had a

significantly higher effective rate, a higher conversion rate of urine ketone, an improvement rate of nausea and

vomiting, and a relatively higher improvement rate of food intake. Acupuncture also shortened hospitalization

time and manifested with a lower pregnancy termination rate and fewer adverse events. Nevertheless, no

statistical variation in the improvement of nausea intensity, vomiting episodes, and lassitude symptom,

recurrence rate, and serum potassium was observed. Authors concluded suggested that acupuncture was

effective in treating HG. However, as the potential inferior quality and underlying publication bias were found in

the included studies, there is a need for more superior-quality RCTs to examine their effectiveness and safety.

Mora et al. (2022) performed a systematic review and meta-analysis about the use and effect of complementary

and alternative medicine (CAM) modalities to treat adverse effects of conventional cancer treatment among

children and young adults. Twenty RCTs comprising 1,069 participants were included in this review. The

included studies investigated acupuncture, mind-body therapies, supplements, and vitamins for chemotherapy-

induced nausea and vomiting (CINV), oral mucositis, and anxiety among children and young adults who

underwent conventional cancer treatment. Seven studies (315 participants) were included in the meta-analysis.

The overall effect of CAM (including acupuncture and hypnosis only) on chemotherapy-induced nausea and/or

vomiting and controls was statistically significant. There was a significant difference between acupuncture and

controls (n = 5) for intensity and/or episodes of CINV. Authors concluded that current evidence from this meta-

analysis of randomized controlled trials shows that CAM, including acupuncture and hypnosis only, is effective

in reducing chemotherapy-induced nausea and vomiting in children and young adults. More rigorous trials and

long-term effects should be investigated if acupuncture and hypnosis are to be recommended for clinical use.

Acupuncture Point Injection Therapy: There is insufficient evidence in the peer-reviewed published scientific

literature to support safety and efficacy of acupuncture point injection therapy (Wang et al., 2015; Cho et al.,

2018; Huang et al., 2019; Xie et al, 2020; Yang et al., 2020). Data comparing the effectiveness of different

products, methods of stimulation and overall clinical utility is lacking.

Providers of Acupuncture Services: Acupuncture services are delivered by a qualified provider of

acupuncture acting within the scope of their license as regulated by the Federal and State governments.

Generally, only those healthcare practitioners who hold an active license, certification, or registration with the

applicable state board or agency may provide services. Benefits for services provided by these healthcare

providers may also be dependent upon the member’s benefit contract language.

Note: 1) This list of codes may not be all-inclusive.

2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible

for reimbursement.

Considered Medically Necessary when criteria in the applicable policy statements listed above are met:

CPT

Codes

Description

97810

Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal

one-on-one contact with the patient

Acupuncture (CPG 024)

Page 18 of 32

97811

Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of

personal one-one contact with the patient, with re-insertion of needle(s) (List separately in

addition to code for primary procedure)

97813

Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-

on-one contact with the patient

97814

Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of

personal one-one contact with the patient, with re-insertion of needle(s) (List separately in

addition to code for primary procedure)

ICD-10-CM

Diagnosis

Codes

Description

G43.001-

G43.919

Migraine

G44.201

Tension-type headache, unspecified, intractable

G44.209

Tension-type headache, unspecified, not intractable

G44.211

Episodic tension-type headache, intractable

G44.219

Episodic tension-type headache, not intractable

G44.221-

G44.229

Chronic tension-type headache

G44.301-

G44.329

Post traumatic headache

G89.11

Acute pain due to trauma

G89.12

Acute post-thoracotomy pain

G89.18

Other chronic postprocedural pain

G89.29

Other chronic pain

G89.3

Neoplasm related pain (acute) (chronic)

G89.4

Chronic pain syndrome

K91.0

Vomiting following gastrointestinal surgery

M16.0-

M16.9

Osteoarthritis of hip

M17.0-

M17.9

Osteoarthritis of knee

M18.0-

M18.9

Osteoarthritis of first carpometacarpal joint

M19.011-

M19.93

Other and unspecified osteoarthritis

M25.511

Pain in right shoulder

M25.512

Pain in left shoulder

M25.519

Pain in unspecified shoulder

M25.521

Pain in right elbow

M25.522

Pain in left elbow

M25.529

Pain in unspecified elbow

M25.531

Pain in right wrist

M25.532

Pain in left wrist

M25.539

Pain in unspecified wrist

M25.541

Pain in joints of right hand

M25.542

Pain in joints of left hand

M25.549

Pain in joints of unspecified hand

M25.551

Pain in right hip

M25.552

Pain in left hip

M25.559

Pain in unspecified hip

M25.561

Pain in right knee

Acupuncture (CPG 024)

Page 19 of 32

M25.562

Pain in left knee

M25.569

Pain in unspecified knee

M25.571

Pain in right ankle and joints of right foot

M25.572

Pain in left ankle and joints of left foot

M25.579

Pain in unspecified ankle and joints of unspecified foot

M47.11

Other spondylosis with myelopathy, occipito-atlanto-axial region

M47.12

Other spondylosis with myelopathy, cervical region

M47.13

Other spondylosis with myelopathy, cervicothoracic region

M47.16

Other spondylosis with myelopathy, lumbar region

M47.21

Other spondylosis with radiculopathy, occipito-atlanto-axial region

M47.22

Other spondylosis with radiculopathy, cervical region

M47.23

Other spondylosis with radiculopathy, cervicothoracic region

M47.24

Other spondylosis with radiculopathy, thoracic region

M47.25

Other spondylosis with radiculopathy, thoracolumbar region

M47.26

Other spondylosis with radiculopathy, lumbar region

M47.27

Other spondylosis with radiculopathy, lumbosacral region

M47.28

Other spondylosis with radiculopathy, sacral and sacrococcygeal region

M47.811

Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region

M47.812

Spondylosis without myelopathy or radiculopathy, cervical region

M47.813

Spondylosis without myelopathy or radiculopathy, cervicothoracic region

M47.814

Spondylosis without myelopathy or radiculopathy, thoracic region

M47.815

Spondylosis without myelopathy or radiculopathy, thoracolumbar region

M47.816

Spondylosis without myelopathy or radiculopathy, lumbar region

M47.817

Spondylosis without myelopathy or radiculopathy, lumbosacral region

M47.818

Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region

M47.891

Other spondylosis, occipito-atlanto-axial region

M47.892

Other spondylosis, cervical region

M47.893

Other spondylosis, cervicothoracic region

M47.894

Other spondylosis, thoracic region

M47.895

Other spondylosis, thoracolumbar region

M47.896

Other spondylosis, lumbar region

M47.897

Other spondylosis, lumbosacral region

M47.898

Other spondylosis, sacral and sacrococcygeal region

M48.01

Spinal stenosis, occipito-atlanto-axial region

M48.02

Spinal stenosis, cervical region

M48.03

Spinal stenosis, cervicothoracic region

M48.04

Spinal stenosis, thoracic region

M48.05

Spinal stenosis, thoracolumbar region

M48.061

Spinal stenosis, lumbar region without neurogenic claudication

M48.07

Spinal stenosis, lumbosacral region

M48.08

Spinal stenosis, sacral and sacrococcygeal region

M50.00

Cervical disc disorder with myelopathy, unspecified cervical region

M50.01

Cervical disc disorder with myelopathy, high cervical region

M50.020

Cervical disc disorder with myelopathy, mid-cervical region, unspecified level

M50.021

Cervical disc disorder at C4-C5 level with myelopathy

M50.022

Cervical disc disorder at C5-C6 level with myelopathy

M50.023

Cervical disc disorder at C6-C7 level with myelopathy

M50.03

Cervical disc disorder with myelopathy, cervicothoracic region

M50.11

Cervical disc disorder with radiculopathy, high cervical region

M50.120

Mid-cervical disc disorder, unspecified level

M50.121

Cervical disc disorder at C4-C5 level with radiculopathy

M50.122

Cervical disc disorder at C5-C6 level with radiculopathy

M50.123

Cervical disc disorder at C6-C7 level with radiculopathy

M50.13

Cervical disc disorder with radiculopathy, cervicothoracic region

M50.20

Other cervical disc displacement, unspecified cervical region

Acupuncture (CPG 024)

Page 20 of 32

M50.21

Other cervical disc displacement, high cervical region

M50.220

Other cervical disc displacement, mid-cervical region, unspecified level

M50.221

Other cervical disc displacement at C4-C5 level

M50.222

Other cervical disc displacement at C5-C6 level

M50.223

Other cervical disc displacement at C6-C7 level

M50.23

Other cervical disc displacement, cervicothoracic region

M50.30

Other cervical disc degeneration, unspecified cervical region

M50.31

Other cervical disc degeneration, high cervical region

M50.320

Other cervical disc degeneration, mid-cervical region, unspecified level

M50.321

Other cervical disc degeneration at C4-C5 level

M50.322

Other cervical disc degeneration at C5-C6 level

M50.323

Other cervical disc degeneration at C6-C7 level

M50.33

Other cervical disc degeneration, cervicothoracic region

M51.06

Intervertebral disc disorders with myelopathy, lumbar region

M51.14

Intervertebral disc disorders with radiculopathy, thoracic region

M51.15

Intervertebral disc disorders with radiculopathy, thoracolumbar region

M51.16

Intervertebral disc disorders with radiculopathy, lumbar region

M51.17

Intervertebral disc disorders with radiculopathy, lumbosacral region

M51.24

Other intervertebral disc displacement, thoracic region

M51.25

Other intervertebral disc displacement, thoracolumbar region

M51.26

Other intervertebral disc displacement, lumbar region

M51.27

Other intervertebral disc displacement, lumbosacral region

M51.34

Other intervertebral disc degeneration, thoracic region

M51.35

Other intervertebral disc degeneration, thoracolumbar region

M51.36

Other intervertebral disc degeneration, lumbar region

M51.37

Other intervertebral disc degeneration, lumbosacral region

M51.84

Other intervertebral disc disorders, thoracic region

M51.85

Other intervertebral disc disorders, thoracolumbar region

M51.86

Other intervertebral disc disorders, lumbar region

M51.87

Other intervertebral disc disorders, lumbosacral region

M51.A1

Intervertebral annulus fibrosus defect, small, lumbar region

M51.A2

Intervertebral annulus fibrosus defect, large, lumbar region

M51.A4

Intervertebral annulus fibrosus defect, small, lumbosacral region

M51.A5

Intervertebral annulus fibrosus defect, large, lumbosacral region

M53.0

Cervicocranial syndrome

M53.1

Cervicobrachial syndrome

M53.3

Sacrococcygeal disorders, not elsewhere classified

M54.2

Cervicalgia

M54.30-

M54.32

Sciatica

M54.40-

M54.42

Lumbago with sciatica

M54.50

Low back pain, unspecified

M54.51

Vertebrogenic low back pain

M54.59

Other low back pain

M54.6

Pain in thoracic spine

M54.89

Other dorsalgia

M54.9

Dorsalgia, unspecified

M77.40

Metatarsalgia, unspecified foot

M77.41

Metatarsalgia, right foot

M77.42

Metatarsalgia, left foot

M79.11

Myalgia of mastication muscle

M79.12

Myalgia of auxillary muscles, head and neck

M79.18

Myalgia, other site

M79.2

Neuralgia and neuritis, unspecified

Acupuncture (CPG 024)

Page 21 of 32

M79.601

Pain in right arm

M79.602

Pain in left arm

M79.603

Pain in arm, unspecified

M79.604

Pain in right leg

M79.605

Pain in left leg

M79.606

Pain in leg, unspecified

M79.621

Pain in right upper arm

M79.622

Pain in left upper arm

M79.629

Pain in unspecified upper arm

M79.631

Pain in right forearm

M79.632

Pain in left forearm

M79.639

Pain in unspecified forearm

M79.641

Pain in right hand

M79.642

Pain in left hand

M79.643

Pain in unspecified hand

M79.644

Pain in right finger(s)

M79.645

Pain in left finger(s)

M79.646

Pain in unspecified finger(s)

M79.651

Pain in right thigh

M79.652

Pain in left thigh

M79.659

Pain in unspecified thigh

M79.661

Pain in right lower leg

M79.662

Pain in left lower leg

M79.669

Pain in unspecified lower leg

M79.671

Pain in right foot

M79.672

Pain in left foot

M79.673

Pain in unspecified foot

M79.674

Pain in right toe(s)

M79.675

Pain in left toe(s)

M79.676

Pain in unspecified toe(s)

M79.7

Fibromyalgia

M99.01

Segmental and somatic dysfunction of cervical region

M99.02

Segmental and somatic dysfunction of thoracic region

M99.03

Segmental and somatic dysfunction of lumbar region

M99.04

Segmental and somatic dysfunction of sacral region

M99.05

Segmental and somatic dysfunction of pelvic region

M99.06

Segmental and somatic dysfunction of lower extremity

M99.07

Segmental and somatic dysfunction of upper extremity

M99.08

Segmental and somatic dysfunction of rib cage

M99.11

Subluxation complex (vertebral) of cervical region

M99.12

Subluxation complex (vertebral) of thoracic region

M99.13

Subluxation complex (vertebral) of lumbar region

M99.14

Subluxation complex (vertebral) of sacral region

M99.15

Subluxation complex (vertebral) of pelvic region

M99.16

Subluxation complex (vertebral) of lower extremity

M99.17

Subluxation complex (vertebral) of upper extremity

M99.18

Subluxation complex (vertebral) of rib cage

M99.21

Subluxation stenosis of neural canal of cervical region

M99.22

Subluxation stenosis of neural canal of thoracic region

M99.23

Subluxation stenosis of neural canal of lumbar region

M99.24

Subluxation stenosis of neural canal of sacral region

M99.25

Subluxation stenosis of neural canal of pelvic region

M99.26

Subluxation stenosis of neural canal of lower extremity

M99.27

Subluxation stenosis of neural canal of upper extremity

M99.28

Subluxation stenosis of neural canal of rib cage

Acupuncture (CPG 024)

Page 22 of 32

M99.31

Osseous stenosis of neural canal of cervical region

M99.32

Osseous stenosis of neural canal of thoracic region

M99.33

Osseous stenosis of neural canal of lumbar region

M99.34

Osseous stenosis of neural canal of sacral region

M99.35

Osseous stenosis of neural canal of pelvic region

M99.36

Osseous stenosis of neural canal of lower extremity

M99.37

Osseous stenosis of neural canal of upper extremity

M99.38

Osseous stenosis of neural canal of rib cage

M99.41

Connective tissue stenosis of neural canal of cervical region

M99.42

Connective tissue stenosis of neural canal of thoracic region

M99.43

Connective tissue stenosis of neural canal of lumbar region

M99.44

Connective tissue stenosis of neural canal of sacral region

M99.45

Connective tissue stenosis of neural canal of pelvic region

M99.46

Connective tissue stenosis of neural canal of lower extremity

M99.47

Connective tissue stenosis of neural canal of upper extremity

M99.48

Connective tissue stenosis of neural canal of rib cage

M99.51

Intervertebral disc stenosis of neural canal of cervical region

M99.52

Intervertebral disc stenosis of neural canal of thoracic region

M99.53

Intervertebral disc stenosis of neural canal of lumbar region

M99.54

Intervertebral disc stenosis of neural canal of sacral region

M99.55

Intervertebral disc stenosis of neural canal of pelvic region

M99.56

Intervertebral disc stenosis of neural canal of lower extremity

M99.57

Intervertebral disc stenosis of neural canal of upper extremity

M99.58

Intervertebral disc stenosis of neural canal of rib cage

M99.61

Osseous and subluxation stenosis of intervertebral foramina of cervical region

M99.62

Osseous and subluxation stenosis of intervertebral foramina of thoracic region

M99.63

Osseous and subluxation stenosis of intervertebral foramina of lumbar region

M99.64

Osseous and subluxation stenosis of intervertebral foramina of sacral region

M99.65

Osseous and subluxation stenosis of intervertebral foramina of pelvic region

M99.66

Osseous and subluxation stenosis of intervertebral foramina of lower extremity

M99.67

Osseous and subluxation stenosis of intervertebral foramina of upper extremity

M99.68

Osseous and subluxation stenosis of intervertebral foramina of rib cage

M99.71

Connective tissue and disc stenosis of intervertebral foramina of cervical region

M99.72

Connective tissue and disc stenosis of intervertebral foramina of thoracic region

M99.73

Connective tissue and disc stenosis of intervertebral foramina of lumbar region

M99.74

Connective tissue and disc stenosis of intervertebral foramina of sacral region

M99.75

Connective tissue and disc stenosis of intervertebral foramina of pelvic region

M99.76

Connective tissue and disc stenosis of intervertebral foramina of lower extremity

M99.77

Connective tissue and disc stenosis of intervertebral foramina of upper extremity

M99.78

Connective tissue and disc stenosis of intervertebral foramina of rib cage

O21.0-

O21.9

Excessive vomiting in pregnancy

R07.82

Intercostal pain

R07.9

Chest pain, unspecified

R11.0

Nausea

R11.10

Vomiting, unspecified

R11.11

Vomiting without nausea

R11.12

Projectile vomiting

R11.2

Nausea with vomiting, unspecified

R51.0

Headache with orthostatic component, not elsewhere classified

R51.9

Headache, unspecified

S13.4XXA

Sprain of ligaments of cervical spine, initial encounter

S13.4XXD

Sprain of ligaments of cervical spine, subsequent encounter

S13.4XXS

Sprain of ligaments of cervical spine, sequela

S13.8XXA

Sprain of joints and ligaments of other parts of neck, initial encounter

Acupuncture (CPG 024)

Page 23 of 32

S13.8XXD

Sprain of joints and ligaments of other parts of neck, subsequent encounter

S13.8XXS

Sprain of joints and ligaments of other parts of neck, sequela

S16.1XXA

Strain of muscle, fascia and tendon at neck level, initial encounter

S16.1XXD

Strain of muscle, fascia and tendon at neck level, subsequent encounter

S16.1XXS

Strain of muscle, fascia and tendon at neck level, sequela

S16.8XXA

Other specified injury of muscle, fascia and tendon at neck level, initial encounter

S16.8XXD

Other specified injury of muscle, fascia and tendon at neck level, subsequent encounter

S16.8XXS

Other specified injury of muscle, fascia and tendon at neck level, sequela

S23.3XXA

Sprain of ligaments of thoracic spine, initial encounter

S23.3XXD

Sprain of ligaments of thoracic spine, subsequent encounter

S23.3XXS

Sprain of ligaments of thoracic spine, sequela

S23.8XXA

Sprain of other specified parts of thorax, initial encounter

S23.8XXD

Sprain of other specified parts of thorax, subsequent encounter

S23.8XXS

Sprain of other specified parts of thorax, sequela

S29.011A

Strain of muscle and tendon of front wall of thorax, initial encounter

S29.011D

Strain of muscle and tendon of front wall of thorax, subsequent encounter

S29.011S

Strain of muscle and tendon of front wall of thorax, sequela

S29.012A

Strain of muscle and tendon of back wall of thorax, initial encounter

S29.012D

Strain of muscle and tendon of back wall of thorax, subsequent encounter

S29.012S

Strain of muscle and tendon of back wall of thorax, sequela

S33.5XXA

Sprain of ligaments of lumbar spine, initial encounter

S33.5XXD

Sprain of ligaments of lumbar spine, subsequent encounter

S33.5XXS

Sprain of ligaments of lumbar spine, sequela

S33.6XXA

Sprain of sacroiliac joint, initial encounter

S33.6XXD

Sprain of sacroiliac joint, subsequent encounter

S33.6XXS

Sprain of sacroiliac joint, sequela

S33.8XXA

Sprain of other parts of lumbar spine and pelvis, initial encounter

S33.8XXD

Sprain of other parts of lumbar spine and pelvis, subsequent encounter

S33.8XXS

Sprain of other parts of lumbar spine and pelvis, sequela

S39.012A

Strain of muscle, fascia and tendon of lower back, initial encounter

S39.012D

Strain of muscle, fascia and tendon of lower back, subsequent encounter

S39.012S

Strain of muscle, fascia and tendon of lower back, sequela

S39.013A

Strain of muscle, fascia and tendon of pelvis, initial encounter

S39.013D

Strain of muscle, fascia and tendon of pelvis, subsequent encounter

S39.013S

Strain of muscle, fascia and tendon of pelvis, sequela

S43.491A

Other sprain of right shoulder joint, initial encounter

S43.491D

Other sprain of right shoulder joint, subsequent encounter

S43.491S

Other sprain of right shoulder joint, sequela

S43.492A

Other sprain of left shoulder joint, initial encounter

S43.492D

Other sprain of left shoulder joint, subsequent encounter

S43.492S

Other sprain of left shoulder joint, sequela

S43.81XA

Sprain of other specified parts of right shoulder girdle, initial encounter

S43.81XD

Sprain of other specified parts of right shoulder girdle, subsequent encounter

S43.81XS

Sprain of other specified parts of right shoulder girdle, sequela

S43.82XA

Sprain of other specified parts of left shoulder girdle, initial encounter

S43.82XD

Sprain of other specified parts of left shoulder girdle, subsequent encounter

S43.82XS

Sprain of other specified parts of left shoulder girdle, sequela

S46.811A

Strain of other muscles, fascia and tendons at shoulder and upper arm level, right arm, initial

encounter

S46.811D

Strain of other muscles, fascia and tendons at shoulder and upper arm level, right arm,

subsequent encounter

S46.811S

Strain of other muscles, fascia and tendons at shoulder and upper arm level, right arm, sequela

S46.812A

Strain of other muscles, fascia and tendons at shoulder and upper arm level, left arm, initial

encounter

Acupuncture (CPG 024)

Page 24 of 32

S46.812D

Strain of other muscles, fascia and tendons at shoulder and upper arm level, left arm,

subsequent encounter

S46.812S

Strain of other muscles, fascia and tendons at shoulder and upper arm level, left arm, sequela

S53.411A

Radiohumeral (joint) sprain of right elbow, initial encounter

S53.411D

Radiohumeral (joint) sprain of right elbow, subsequent encounter

S53.411S

Radiohumeral (joint) sprain of right elbow, sequela

S53.412A

Radiohumeral (joint) sprain of left elbow, initial encounter

S53.412D

Radiohumeral (joint) sprain of left elbow, subsequent encounter

S53.412S

Radiohumeral (joint) sprain of left elbow, sequela

S53.419A

Radiohumeral (joint) sprain of unspecified elbow, initial encounter

S53.419D

Radiohumeral (joint) sprain of unspecified elbow, subsequent encounter

S53.419S

Radiohumeral (joint) sprain of unspecified elbow, sequela

S53.421A

Ulnohumeral (joint) sprain of right elbow, initial encounter

S53.421D

Ulnohumeral (joint) sprain of right elbow, subsequent encounter

S53.421S

Ulnohumeral (joint) sprain of right elbow, sequela

S53.422A

Ulnohumeral (joint) sprain of left elbow, initial encounter

S53.422D

Ulnohumeral (joint) sprain of left elbow, subsequent encounter

S53.422S

Ulnohumeral (joint) sprain of left elbow, sequela

S53.429A

Ulnohumeral (joint) sprain of unspecified elbow, initial encounter

S53.429D

Ulnohumeral (joint) sprain of unspecified elbow, subsequent encounter

S53.429S

Ulnohumeral (joint) sprain of unspecified elbow, sequela

S53.431A

Radial collateral ligament sprain of right elbow, initial encounter

S53.431D

Radial collateral ligament sprain of right elbow, subsequent encounter

S53.431S

Radial collateral ligament sprain of right elbow, sequela

S53.432A

Radial collateral ligament sprain of left elbow, initial encounter

S53.432D

Radial collateral ligament sprain of left elbow, subsequent encounter

S53.432S

Radial collateral ligament sprain of left elbow, sequela

S53.439A

Radial collateral ligament sprain of unspecified elbow, initial encounter

S53.439D

Radial collateral ligament sprain of unspecified elbow, subsequent encounter

S53.439S

Radial collateral ligament sprain of unspecified elbow, sequela

S53.441A

Ulnar collateral ligament sprain of right elbow, initial encounter

S53.441D

Ulnar collateral ligament sprain of right elbow, subsequent encounter

S53.441S

Ulnar collateral ligament sprain of right elbow, sequela

S53.442A

Ulnar collateral ligament sprain of left elbow, initial encounter

S53.442D

Ulnar collateral ligament sprain of left elbow, subsequent encounter

S53.442S

Ulnar collateral ligament sprain of left elbow, sequela

S53.449A

Ulnar collateral ligament sprain of unspecified elbow, initial encounter

S53.449D

Ulnar collateral ligament sprain of unspecified elbow, subsequent encounter

S53.449S

Ulnar collateral ligament sprain of unspecified elbow, sequela

S53.491A

Other sprain of right elbow, initial encounter

S53.491D

Other sprain of right elbow, subsequent encounter

S53.491S

Other sprain of right elbow, sequela

S53.492A

Other sprain of left elbow, initial encounter

S53.492D

Other sprain of left elbow, subsequent encounter

S53.492S

Other sprain of left elbow, sequela

S63.591A

Other specified sprain of right wrist, initial encounter

S63.591D

Other specified sprain of right wrist, subsequent encounter

S63.591S

Other specified sprain of right wrist, sequela

S63.592A

Other specified sprain of left wrist, initial encounter

S63.592D

Other specified sprain of left wrist, subsequent encounter

S63.592S

Other specified sprain of left wrist, sequela

S63.8X1A

Sprain of other part of right wrist and hand, initial encounter

S63.8X1D

Sprain of other part of right wrist and hand, subsequent encounter

S63.8X1S

Sprain of other part of right wrist and hand, sequela

S63.8X2A

Sprain of other part of left wrist and hand, initial encounter

Acupuncture (CPG 024)

Page 25 of 32

S63.8X2D

Sprain of other part of left wrist and hand, subsequent encounter

S63.8X2S

Sprain of other part of left wrist and hand, sequela

S73.191A

Other sprain of right hip, initial encounter

S73.191D

Other sprain of right hip, subsequent encounter

S73.191S

Other sprain of right hip, sequela

S73.192A

Other sprain of left hip, initial encounter

S73.192D

Other sprain of left hip, subsequent encounter

S73.192S

Other sprain of left hip, sequela

S83.411A

Sprain of medial collateral ligament of right knee, initial encounter

S83.411D

Sprain of medial collateral ligament of right knee, subsequent encounter

S83.411S

Sprain of medial collateral ligament of right knee, sequela

S83.412A

Sprain of medial collateral ligament of left knee, initial encounter

S83.412D

Sprain of medial collateral ligament of left knee, subsequent encounter

S83.412S

Sprain of medial collateral ligament of left knee, sequela

S83.421A

Sprain of lateral collateral ligament of right knee, initial encounter

S83.421D

Sprain of lateral collateral ligament of right knee, subsequent encounter

S83.421S

Sprain of lateral collateral ligament of right knee, sequela

S83.422A

Sprain of lateral collateral ligament of left knee, initial encounter

S83.422D

Sprain of lateral collateral ligament of left knee, subsequent encounter

S83.422S

Sprain of lateral collateral ligament of left knee, sequela

S83.511A

Sprain of anterior cruciate ligament of right knee, initial encounter

S83.511D

Sprain of anterior cruciate ligament of right knee, subsequent encounter

S83.511S

Sprain of anterior cruciate ligament of right knee, sequela

S83.512A

Sprain of anterior cruciate ligament of left knee, initial encounter

S83.512D

Sprain of anterior cruciate ligament of left knee, subsequent encounter

S83.512S

Sprain of anterior cruciate ligament of left knee, sequela

S83.521A

Sprain of posterior cruciate ligament of right knee, initial encounter

S83.521D

Sprain of posterior cruciate ligament of right knee, subsequent encounter

S83.521S

Sprain of posterior cruciate ligament of right knee, sequela

S83.522A

Sprain of posterior cruciate ligament of left knee, initial encounter

S83.522D

Sprain of posterior cruciate ligament of left knee, subsequent encounter

S83.522S

Sprain of posterior cruciate ligament of left knee, sequela

S83.8X1A

Sprain of other specified parts of right knee, initial encounter

S83.8X1D

Sprain of other specified parts of right knee, subsequent encounter

S83.8X1S

Sprain of other specified parts of right knee, sequela

S83.8X2A

Sprain of other specified parts of left knee, initial encounter

S83.8X2D

Sprain of other specified parts of left knee, subsequent encounter

S83.8X2S

Sprain of other specified parts of left knee, sequela

S83.91XA

Sprain of unspecified site of right knee, initial encounter

S83.91XD

Sprain of unspecified site of right knee, subsequent encounter

S83.91XS

Sprain of unspecified site of right knee, sequela

S83.92XA

Sprain of unspecified site of left knee, initial encounter

S83.92XD

Sprain of unspecified site of left knee, subsequent encounter

S83.92XS

Sprain of unspecified site of left knee, sequela

S93.401A

Sprain of unspecified ligament of right ankle, initial encounter

S93.401D

Sprain of unspecified ligament of right ankle, subsequent encounter

S93.401S

Sprain of unspecified ligament of right ankle, sequela

S93.402A

Sprain of unspecified ligament of left ankle, initial encounter

S93.402D

Sprain of unspecified ligament of left ankle, subsequent encounter

S93.402S

Sprain of unspecified ligament of left ankle, sequela

Considered Experimental, investigational or unproven when used to report acupuncture for any other

indication (including infertility and recurrent pregnancy loss):

Acupuncture (CPG 024)

Page 26 of 32

ICD-10-CM

Diagnosis

Codes

Description

All other codes

Acupuncture Point Injection

Considered Experimental, investigational or unproven when used to report acupuncture point injection

therapy:

CPT

Codes

Description

20550

Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")

20551

Injection(s); single tendon origin/insertion

20552

Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

20553

Injection(s); single or multiple trigger point(s), 3 or more muscle(s)

*Current Procedural Terminology (CPT

)

2022 American Medical Association: Chicago, IL.

References

1. Abe H, Inoue R, Tsuchida R, et al. Efficacy of treatments for pain and numbness in cancer survivors: a

systematic review and meta-analysis. Ann Palliat Med. 2022;11(12):3674-3696. doi:10.21037/apm-22-

420

2. Atalay SG, Durmus A, Gezginaslan Ö. The Effect of Acupuncture and Physiotherapy on Patients with

Knee Osteoarthritis: A Randomized Controlled Study. Pain Physician. 2021;24(3):E269-E278.

3. American Medical Association. (2018). Current Procedural Terminology (CPT) Current year (rev. ed.).

Chicago: AMA.

4. Babatunde OO, Ensor J, Littlewood C, et al. Comparative effectiveness of treatment options for

subacromial shoulder conditions: a systematic review and network meta-analysis. Ther Adv

Musculoskelet Dis. 2021;13:1759720X211037530. Published 2021 Sep 9.

5. Bannuru RR, McAlindon TE, Sullivan MC, Wong JB, Kent DM, Schmid CH. Effectiveness and

Implications of Alternative Placebo Treatments: A Systematic Review and Network Meta-analysis of

Osteoarthritis Trials. Ann Intern Med. 2015 Sep 1;163(5):365-72.

6. Baroncini A, Maffulli N, Eschweiler J, Molsberger F, Klimuch A, Migliorini F. Acupuncture in chronic

aspecific low back pain: a Bayesian network meta-analysis. J Orthop Surg Res. 2022;17(1):319.

Published 2022 Jun 20. doi:10.1186/s13018-022-03212-3

7. Ben-Arye E, Hausner D, Samuels N, et al. Impact of acupuncture and integrative therapies on

chemotherapy-induced peripheral neuropathy: A multicentered, randomized controlled trial. Cancer.

2022;128(20):3641-3652. doi:10.1002/cncr.34422

8. Casimiro L, Barnsley L, Brosseau L, Milne S, Robinson VA, Tugwell P, Wells G. Acupuncture and

electroacupuncture for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev. 2005 Oct

19;(4):CD003788.

9. Centers for Medicaid and Medicare Services (CMS) National Coverage Determinations (NCDs). (2020).

Acupuncture. NCD 30.3. Retrieved on February 9, 2023 from https://www.cms.gov/medicare-coverage-

database/(S(cnbxfa45qfwykj45ydhic5qj))/details/ncd-

details.aspx?NCDId=11&NCAId=2&NcaName=Acupuncture+for+Nausea+after+Chemotherapy+and+P

ost-operative+Pain&bc=AAAAABAAEAgA

Acupuncture (CPG 024)

Page 27 of 32

10. Centers for Medicaid and Medicare Services (CMS) National Coverage Determinations (NCDs). NCD

30.3.1 Acupuncture for Fibromyalgia.

11. Centers for Medicaid and Medicare Services (CMS) National Coverage Determinations (NCDs). NCD

30.3.2 Acupuncture for Osteoarthritis

12. Centers for Medicaid and Medicare Services (CMS) Decision Memo for Acupuncture for Chronic Low

Back Pain (CAG-00452N). Retrieved on February 9, 2023 from https://www.cms.gov/medicare-

coverage-database/details/nca-decision-memo.aspx?NCAId=295

13. Cho YJ, Song YK, Cha YY, Shin BC, Shin IH, Park HJ, Lee HS, Kim KW, Cho JH, Chung WS, Lee JH,

Song MY. Acupuncture for chronic low back pain: a multicenter, randomized, patient-assessor blind,

sham-controlled clinical trial. Spine (Phila Pa 1976). 2013 Apr 1;38(7):549-5.

14. Cho KH, Kim TH, Jung WS, Moon SK, Ko CN, Cho SY, Jeon CY, Choi TY, Lee MS, Lee 30 SH, Chung

EK, Kwon S. Pharmacoacupuncture for Idiopathic Parkinson's Disease: A 31 Systematic Review of

Randomized Controlled Trials. Evid Based Complement 32 Alternat Med. 2018 Jun

25;2018:3671542.

15. Choi TY, Kim TH, Kang JW, Lee MS, Ernst E. Moxibustion for rheumatic conditions: a systematic review

and meta-analysis. Clin Rheumatol. 2011;30(7):937-45.

16. Choi TY, Choi J, Kim KH, Lee MS. Moxibustion for the treatment of osteoarthritis: a systematic review

and meta-analysis. Rheumatol Int. 2012;32(10):2969-78.

17. Cox J, Varatharajan S, Côté P, Optima Collaboration. Effectiveness of Acupuncture Therapies to

Manage Musculoskeletal Disorders of the Extremities: A Systematic Review. J Orthop Sports Phys

Ther. 2016 Jun;46(6):409-29.

18. Crawford PF 3rd, Moss DA, Hawks MK, Snyder MJ. Integrative Medicine: Acupuncture. FP Essent.

2021;505:18-22.

19. Deare JC, Zheng Z, Xue CC, Liu JP, Shang J, Scott SW, Littlejohn G. Acupuncture for treating

fibromyalgia. Cochrane Database Syst Rev. 2013 May 31;5:CD007070.

20. Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh BB. Is acupuncture effective for the treatment

of chronic pain? A systematic review. Pain. 2000 Jun;86(3):217-25.

21. Ezzo JM, Richardson MA, Vickers A, Allen C, Dibble SL, Issell BF, Lao L, Pearl M, Ramirez G, Roscoe

J, Shen J, Shivnan JC, Streitberger K, Treish I, Zhang G. Acupuncture-point stimulation for

chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD002285.

22. Fredy DM, Harpin D, Mihardja H. The role of acupuncture for myofascial pain syndrome (MPS) in

interventional pain management. J Complement Integr Med. 2022;19(2):213-217. Published 2022 Feb

17. doi:10.1515/jcim-2021-0525

23. Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L, Cherkin D, Gagnier J,

Ammendolia C, Ansari MT, Ostermann T, Dryden T, Doucette S,

Skidmore B, Daniel R, Tsouros S,

Weeks L, Galipeau J. Complementary and alternative therapies for back pain II. Evid Rep Technol

Assess (Full Rep). 2010 Oct;(194):1-764.

24. Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. Acupuncture and dry-

needling for low back pain: an updated systematic review within the framework of the Cochrane

collaboration. Spine (Phila Pa 1976). 2005 Apr 15;30(8):944-63.

25. Garcia MK, McQuade J, Haddad R, Patel S, Lee R, Yang P, Palmer JL, Cohen L. Systematic review of

acupuncture in cancer care: a synthesis of the evidence. Clin Oncol. 2013 Mar 1;31(7):952-60.

Acupuncture (CPG 024)

Page 28 of 32

26. Ge L, Wang Q, He Y, et al. Acupuncture for cancer pain: an evidence-based clinical practice guideline.

Chin Med. 2022;17(1):8. Published 2022 Jan 5. doi:10.1186/s13020-021-00558-4

27. Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W. Acupuncture for lateral

elbow pain. Cochrane Database Syst Rev. 2002;(1):CD003527.

28. Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Cochrane Database Syst Rev. 2005

Apr 18;(2):CD005319

29. Hershman DL, Unger JM, Greenlee H, et al. Comparison of Acupuncture vs Sham Acupuncture or

Waiting List Control in the Treatment of Aromatase Inhibitor-Related Joint Pain: A Randomized Clinical

Trial. JAMA Netw Open. 2022;5(11):e2241720. Published 2022 Nov 1.

doi:10.1001/jamanetworkopen.2022.41720

30. Hinman RS, McCrory P, Pirotta M, Relf I, Forbes A, Crossley KM, Williamson E, Kyriakides M, Novy K,

Metcalf BR Harris A Reddy P, Conaghan PG, Bennell K. Acupuncture for chronic knee pain: a

randomized clinical trial. JAMA. 2014 Oct 1;312(13):1313-22.

31. Hopton A, MacPherson H. Acupuncture for chronic pain: is acupuncture more than an effective

placebo? A systematic review of pooled data from meta-analyses. Pain Pract. 2010 Mar-Apr;10(2):94-

102.

32. Huang JF, Zheng XQ, Chen D, et al. Can Acupuncture Improve Chronic Spinal Pain? A Systematic

Review and Meta-Analysis. Global Spine J. 2021;11(8):1248-1265. doi:10.1177/2192568220962440

33. Huang R, Li X, Xu S, Li D, Yan P, Liu B, Xie X, Yang K. Acupoint injection treatment 34 for primary

osteoporosis: a systematic review and meta-analysis of randomized 35 controlled trials. Ann Palliat

Med. 2019 Nov;8(5):586-595

34. Ju ZY, Wang K, Cui HS, Yao Y, Liu SM, Zhou J, Chen TY, Xia J. Acupuncture for neuropathic pain in

adults. Cochrane Database Syst Rev. 2017 Dec 2;12:CD012057.

35. Kim TH, Lee MS, Kim KH, Kang JW, Choi TY, Ernst E. Acupuncture for treating acute ankle sprains in

adults. Cochrane Database Syst Rev. 2014 Jun 23;6:CD009065.

36. Kim TH, Kim KH, Kang JW, Lee M, Kang KW, Kim JE, Kim JH, Lee S, Shin MS, Jung SY, Kim AR, Park

HJ, Jung HJ, Song HS, Kim HJ, Choi JB, Hong KE, Choi SM.Moxibustion treatment for knee

osteoarthritis: a multi-centre, non-blinded, randomised controlled trial on the effectiveness and safety of

the moxibustion treatment versus usual care in knee osteoarthritis patients. PLoS One. 2014 Jul

25;9(7):e101973.

37. Kim KH, Lee MS, Kim TH, Kang JW, Choi TY, Lee JD. Acupuncture and related interventions for

symptoms of chronic kidney disease. Cochrane Database Syst Rev. 2016 Jun 28;(6):CD009440.

38. Leggit JC. Musculoskeletal Therapies: Acupuncture, Dry Needling, Cupping. FP Essent. 2018

Jul;470:27-31.

39. Lee MS, Choi TY, Kang JW, Lee BJ, Ernst E. Moxibustion for treating pain: a systematic review. Am J

Chin Med. 2010;38(5):829-38.

40. Lu H, Zheng C, Zhong Y, Cheng L, Zhou Y. Effectiveness of Acupuncture in the Treatment of

Hyperemesis Gravidarum: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat

Med. 2021;2021:2731446. Published 2021 Jul 27. doi:10.1155/2021/2731446

41. Knight B, Mudge C, Openshaw S, White A, Hart A. Effect of acupuncture on nausea of pregnancy: a

randomized, controlled trial. Obstet Gynecol. 2001 Feb;97(2):184-8.

42. Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a

systematic review and meta-analysis. Spine (Phila Pa 1976). 2013 Nov 15;38(24):2124-38.

Acupuncture (CPG 024)

Page 29 of 32

43. Lao L, Bergman S, Hamilton GR, Langenberg P, Berman B. Evaluation of acupuncture for pain control

after oral surgery: a placebo-controlled trial. Arch Otolaryngol Head Neck Surg. 1999 May;125(5):567-

72.

44. Lao L, Bergman S, Langenberg P, Wong RH, Berman B. Efficacy of Chinese acupuncture on

postoperative oral surgery pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995

Apr;79(4):423-8.

45. Lee A, Fan LT. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and

vomiting. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003281.

46. Lee S, Lee MS, Choi DH, Lee SK. Electroacupuncture on PC6 prevents opioid-induced nausea and

vomiting after laparoscopic surgery. Chin J Integr Med. 2013 Apr;19(4):277-81.

47. Li H, Schlaeger JM, Jang MK, et al. Acupuncture Improves Multiple Treatment-Related Symptoms in

Breast Cancer Survivors: A Systematic Review and Meta-Analysis. J Altern Complement Med.

2021;27(12):1084-1097. doi:10.1089/acm.2021.0133

48. Lin X, Li F, Lu H, Zhu M, Peng TZ. Acupuncturing of myofascial pain trigger points for the treatment of

knee osteoarthritis: A systematic review and meta-analysis. Medicine (Baltimore). 2022;101(8):e28838.

doi:10.1097/MD.0000000000028838

49. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine

prophylaxis. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001218.

50. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for tension-type

headache. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007587.

51. Liu L, Skinner M, McDonough S, Mabire L, Baxter GD. Acupuncture for low back pain: an overview of

systematic reviews. Evid Based Complement Alternat Med. 2015;2015:328196.

52. MacPherson H, Maschino AC, Lewith G, Foster NE, Witt CM, Vickers AJ; Acupuncture Trialists'

Collaboration. Characteristics of acupuncture treatment associated with outcome: an individual patient

meta-analysis of 17,922 patients with chronic pain in randomised controlled trials. PLoS One. 2013 Oct

11;8(10):e77438.

53. MacPherson H, Vertosick EA, Foster NE, Lewith G, Linde K, Sherman KJ, Witt CM, Vickers AJ. The

persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with

chronic pain. Pain. 2017 May;158(5):784-793.

54. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of

randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ.

2009 Jan 27;338:a3115.

55. Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DA, Berman BM, Bouter LM.

Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst Rev. 2010 Jan

20;(1):CD001977

56. Mao JJ, Ismaila N, Bao T, et al. Integrative Medicine for Pain Management in Oncology: Society for

Integrative Oncology-ASCO Guideline. J Clin Oncol. 2022;40(34):3998-4024.

doi:10.1200/JCO.22.01357

57. Matthews A, Haas DM, O'Mathúna DP, Dowswell T. Interventions for nausea and vomiting in early

pregnancy. Cochrane Database Syst Rev. 2015 Sep 8;9:CD007575.

58. Mora DC, Overvåg G, Jong MC, et al. Complementary and alternative medicine modalities used to treat

adverse effects of anti-cancer treatment among children and young adults: a systematic review and

meta-analysis of randomized controlled trials. BMC Complement Med Ther. 2022;22(1):97. Published

2022 Apr 2. doi:10.1186/s12906-022-03537-w

Acupuncture (CPG 024)

Page 30 of 32

59. Mu J, Furlan AD, Lam WY, Hsu MY, Ning Z, Lao L. Acupuncture for chronic nonspecific low back pain.

Cochrane Database Syst Rev. 2020;12(12):CD013814. Published 2020 Dec 11.

doi:10.1002/14651858.CD013814

60. National Guideline Centre (UK). Evidence review for acupuncture for chronic primary pain: Chronic pain

(primary and secondary) in over 16s: assessment of all chronic pain and management of chronic

primary pain. London: National Institute for Health and Care Excellence (NICE); April 2021.

61. Nielsen A, Dusek JA, Taylor-Swanson L, Tick H. Acupuncture Therapy as an Evidence-Based

Nonpharmacologic Strategy for Comprehensive Acute Pain Care: The Academic Consortium Pain Task

Force White Paper Update. Pain Med. 2022;23(9):1582-1612. doi:10.1093/pm/pnac056

62. Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in adults. Cochrane

Database Syst Rev. 2011 Jan 19;(1):CD007753.

63. Paley CA, Johnson MI, Tashani OA, Bagnall A-M. Acupuncture for cancer pain in adults. Cochrane

Database of Systematic Reviews 2015, Issue 10. Art. No.: CD007753.

64. Rithirangsriroj K, Manchana T, Akkayagorn L. Efficacy of acupuncture in prevention of delayed

chemotherapy induced nausea and vomiting in gynecologic cancer patients. Gynecol Oncol. 2015

Jan;136(1):82-6.

65. Shen Y, Liu L, Chiang JS, Meng Z, Garcia MK, Chen Z, Peng H, Bei W, Zhao Q, Spelman AR, Cohen L.

Randomized, placebo-controlled trial of K1 acupoint acustimulation to prevent cisplatin-induced or

oxaliplatin-induced nausea. Cancer. 2015 Jan 1;121(1):84-92.

66. Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Winter C,

Ferguson AJR. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review.

Comparative Effectiveness Review No. 209. (Prepared by the Pacific Northwest Evidence-based

Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No 18-EHC013-EF.

Rockville, MD: Agency for Healthcare Research and Quality; June 2018.

67. Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Kantner

S, Ferguson AJR. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review

Update [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Apr. Report

No.: 20-EHC009. PMID: 32338846.

68. Smith C, Crowther C. The placebo response and effect of time in a trial of acupuncture to treat nausea

and vomiting in early pregnancy. Complement Ther Med. 2002 Dec;10(4):210-4.

69. Smith C, Crowther C, Beilby J. Acupuncture to treat nausea and vomiting in early pregnancy: a

randomized controlled trial. Birth. 2002 Mar;29(1):1-9.

70. Smith CA, Zhu X, He L, Song J. Acupuncture for primary dysmenorrhea. Cochrane Database Syst Rev.

2011 Jan 19;(1):CD007854. doi: 10.1002/14651858.CD007854.pub2.

71. Su X, Qian H, Chen B, et al. Acupuncture for acute low back pain: a systematic review and meta-

analysis. Ann Palliat Med. 2021;10(4):3924-3936.

72. Tian H, Huang L, Sun M, et al. Acupuncture for Knee Osteoarthritis: A Systematic Review of

Randomized Clinical Trials with Meta-Analyses and Trial Sequential Analyses. Biomed Res Int.

2022;2022:6561633. Published 2022 Apr 21. doi:10.1155/2022/6561633

73. Tice JA, Kumar V, Otuonye I, et al. Cognitive and Mind-Body Therapies for Chronic Low Back and Neck

Pain: Effectiveness and Value, Final Evidence Report, November 6, 2017. The Institute for Clinical and

Economic Review (ICER), prepared for the California Technology Assessment Forum. Retrieved on

February 9, 2023 from https://icer.org/wp-

content/uploads/2020/10/CTAF_LBNP_Final_Evidence_Report_110617.pdf

Acupuncture (CPG 024)

Page 31 of 32

74. Trinh KV, Graham N, Gross AR, Goldsmith CH, Wang E, Cameron ID, Kay T; Cervical Overview Group.

Acupuncture for neck disorders. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004870.

75. Turkistani A, Shah A, Jose AM, et al. Effectiveness of Manual Therapy and Acupuncture in Tension-

Type Headache: A Systematic Review. Cureus. 2021;13(8):e17601. Published 2021 Aug 31.

76. Van Hal M, Dydyk AM, Green MS. Acupuncture. In: StatPearls. Treasure Island (FL): StatPearls

Publishing; July 31, 2021.

77. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, Sherman KJ, Witt CM,

Linde K; Acupuncture Trialists' Collaboration. Acupuncture for chronic pain: individual patient data meta-

analysis. Arch Intern Med. 2012 Oct 22;172(19):1444-53.

78. Wang LQ, Chen Z, Zhang K, Liang N, Yang GY, Lai L, Liu JP. Zusanli (ST36) Acupoint 39 Injection for

Diabetic Peripheral Neuropathy: A Systematic Review of Randomized 40 Controlled Trials. J Altern

Complement Med. 2018 Dec;24(12):1138-1149.

79. Wong JJ, Côté P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low

back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa)

Collaboration. Eur J Pain. 2017;21(2):201-216.

80. Wu B, Yang L, Fu C, et al. Efficacy and safety of acupuncture in treating acute low back pain: a

systematic review and bayesian network meta-analysis. Ann Palliat Med. 2021;10(6):6156-6167.

81. Xiang Y, He J, Li R. Appropriateness of sham or placebo acupuncture for randomized controlled trials of

acupuncture for nonspecific low back pain: a systematic review and meta-analysis. J Pain Res. 2017

(11):83-94.

82. Xie G, Wang T, Tang X, Guo X, Xu Y, Deng L, Sun H, Ma Z, Ai Y, Jiang B, Li L, Luo 17 W, Huang W,

Xia Y, Zhao H, Wang X, Guo Y, Liao J. Acupoint Injection for 18 Nonspecific Chronic Low

Back Pain: A Systematic Review and Meta-Analysis of 19 Randomized Controlled Studies. Evid

Based Complement Alternat Med. 2020 Oct 20 28;2020:3976068.

83. Yang T, Zhao J, Guo Q, Wang Y, Si G. Acupoint injection treatment for non-dialysis 26

dependent chronic kidney disease: A meta-analysis of randomized controlled trials. 27 Medicine

(Baltimore). 2020 Dec 18;99(51):e23306. doi: 28

10.1097/MD.0000000000023306. PMID: 33371063; PMCID: PMC7748216.

84. Yang J, Wahner-Roedler DL, Zhou X, et al. Acupuncture for palliative cancer pain management:

systematic review. BMJ Support Palliat Care. 2021;11(3):264-270.

85. Yang J, Wang Y, Xu J, et al. Acupuncture for low back and/or pelvic pain during pregnancy: a

systematic review and meta-analysis of randomised controlled trials. BMJ Open. 2022;12(12):e056878.

Published 2022 Nov 21. doi:10.1136/bmjopen-2021-056878

86. Yu B, Li M, Huang H, et al. Acupuncture treatment of diabetic peripheral neuropathy: An overview of

systematic reviews. J Clin Pharm Ther. 2021;46(3):585-598.

87. Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese medicine for neck pain and low back

pain: a systematic review and meta-analysis. PLoS One. 2015;10(2):e0117146.

88. Zeng Y and Chung JW. Acupuncture for chronic nonspecific low back pain: An overview of systematic

reviews. European Journal of Integrative Medicine. 2015; 7(2): 94-107.

89. Zhang GL, Yang SY, Zhu ZL, Mu PX. Meta-analysis on postoperative complications of wristband

acupoint pressure therapy. J Biol Regul Homeost Agents. 2015 Jan-Mar;29(1):187-93

Acupuncture (CPG 024)

Page 32 of 32

90. Zhang Y, Sun Y, Li D, et al. Acupuncture for Breast Cancer: A Systematic Review and Meta-Analysis of

Patient-Reported Outcomes. Front Oncol. 2021;11:646315. Published 2021 Jun 10.

doi:10.3389/fonc.2021.646315

91. Zhang XW, Hou WB, Pu FL, et al. Acupuncture for cancer-related conditions: An overview of systematic

reviews. Phytomedicine. 2022;106:154430. doi:10.1016/j.phymed.2022.154430

92. Zheng H, Gao T, Zheng QH, et al. Acupuncture for Patients With Chronic Tension-Type Headache: A

Randomized Controlled Trial [published online ahead of print, 2022 Jun 22]. Neurology.

2022;10.1212/WNL.0000000000200670. doi:10.1212/WNL.0000000000200670

93. Zhao L, Cheng K, Wang L, Wu F, Deng H, Tan M, Lao L, Shen X. Effectiveness of moxibustion

treatment as adjunctive therapy in osteoarthritis of the knee: a randomized, double-blinded, placebo-

controlled clinical trial. Arthritis Res Ther. 2014 Jun 24;16(3):R133.

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