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Coverage decision – Covered with conditions (Effective date: June 1, 2019)

Conditions of Coverage:

The department covers acupuncture, with or without electrical stimulation, up to a maximum of 10 treatments over the lifetime of the claim, for the following conditions only:

  • An accepted lumbar condition on the claim.

In addition, the following requirements must be met:

  • Documentation of the referral from the attending provider must appear in the claim file, and
  • The treatment provided must be only for covered conditions as stated in this policy, and
  • The claim must be allowed and open, and
  • The provider must submit to the claim file validated functional instruments to track and document the worker's pain and functional status at the following visits:
    • The Initial office visit/treatment, and
    • The Middle treatment, and
    • The Final treatment.

Only the medically necessary number of acupuncture treatments should be provided, up to a maximum of 10 treatments over the lifetime of the claim.

Validated functional instruments include:

Non-covered Indications

L&I will not authorize payment for acupuncture treatment related to conditions not listed.

Billing Codes

For billing information, please refer to L&I Fee Schedules and Payment Policies (MARFS).

For more information:
Contact information.

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