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Acupuncturists and Medicare
By Jonathan Blum
Thank you for your petition on recognizing acupuncturists as health care providers under the Social Security Act.
As you noted, acupuncturists are not recognized in the Social Security Act as health care providers who are authorized to bill and receive payment for their services from Medicare. To do so would require a change to the statute by Congress.
The term "provider" is defined in Medicare regulations at 42 C.F.R, §400.202 and includes hospitals, skilled nursing facilities, and home health agencies. That term does not include acupuncturists. Moreover, the Medicare law specifically authorizes the health care providers who can bill and receive payment from Medicare. For instance, section 1861(r) of the Social Security Act defines "physicians" under the Medicare program. This definition includes, with various restrictions and exceptions, doctors of medicine and osteopathy, doctors of dental surgery and dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors. The statute also authorizes several specific non-physician practitioners including nurse practitioners, clinical nurse specialists, physician assistants, nurse midwives, clinical psychologists, and physical therapists to bill and receive payment from Medicare for their professional services that fall within their State scope of practice.
Furthermore, acupuncture is not a covered benefit within the Medicare program. To cover acupuncture would require a change in statute or a change in the CMS National Coverage Determination (NCD).
The overall scope of covered and non-covered benefits under the Medicare program is prescribed by law. Coverage is contingent upon a determination that a service meets a benefit category specified in the Social Security Act, is not specifically excluded from coverage, and the item or service is medically "reasonable and necessary". Section 1862(a)(1)(A) of the Social Security Act states that, subject to certain limited exceptions, no payment may be made for any expenses incurred for items or services that are not "reasonable and necessary" for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
As prescribed by law, CMS develops NCDs. These national policies, which are made through an evidenced based process with opportunity for public participation, serve as generally applicable rules to ensure that similar claims for items and services are covered in the same manner. NCDs may grant, limit, or exclude Medicare coverage for particular items and services, and there are three NCDs on acupuncture. After careful study of the available evidence, it was concluded that acupuncture is not reasonable and necessary under section 1862(a)(1) of the Social Security Act. Therefore national noncoverage for acupuncture continues.
For more detailed information on National or Local Coverage of acupuncture services, please visit the Medicare Coverage Database on CMS.HHS.gov. Further information about the NCD process can be found in the Federal Register here (PDF).
Jonathan Blum is the Principal Deputy Administrator at the Centers for Medicare & Medicaid Services.