Aetna may cover acupuncture when it is deemed medically necessary and performed by a licensed acupuncturist or other recognized healthcare provider. Coverage depends on your specific Aetna plan and state, so always confirm directly with Aetna before beginning treatment.
Aetna’s Clinical Policy Bulletin 0135 (Acupuncture and Dry Needling) outlines when acupuncture is considered medically necessary. However, your benefit plan governs payment and may differ from the policy guidelines.
Is Acupuncture Covered by Aetna?
Yes.
Aetna may cover acupuncture when used to treat conditions such as chronic pain, migraines, postoperative nausea, or osteoarthritis.
Coverage typically applies when:
- The treatment is ordered or supervised by a licensed medical professional.
- It targets a covered diagnosis such as chronic low back pain, tension headache, or post-surgical nausea.
- It is provided by a credentialed, licensed acupuncturist.
- Documentation of medical necessity is supplied.
Refer to your plan’s summary or the member portal for exact coverage and exclusions.
Is Acupuncture Covered in a Standalone Acupuncture Clinic?
Sometimes.
Certain Aetna plans allow coverage when acupuncture is performed by a licensed and credentialed provider, including those in private or standalone clinics. However, other plans may require that the acupuncturist work under the supervision of a medical doctor or be part of an approved Aetna network.
Check your plan’s provider requirements before scheduling treatment.
What Conditions Must Be Met for Acupuncture Coverage?
According to Aetna’s CPB 0135, acupuncture may be covered when:
- It is ordered or supervised by a licensed clinician.
- It is used for a covered condition, such as:
- Chronic neck pain
- Chronic headache (including tension-type)
- Chronic low back pain
- Osteoarthritis pain (adjunctive therapy)
- Nausea or vomiting of pregnancy
- Chemotherapy- or post-surgery–related nausea
- Post-operative dental pain
- It is performed by a licensed, credentialed provider.
- Documentation supports medical necessity.
Your plan document may specify additional or fewer covered conditions.
Does Acupuncture Require Pre-Authorization?
Yes, in many cases.
Aetna often requires pre-certification for acupuncture services before treatment begins. Your healthcare provider will typically submit:
- Diagnosis codes and documentation
- A detailed treatment plan
- Supporting clinical notes
You or your provider can check pre-certification requirements through your Aetna member portal.
How Do I Get Pre-Authorization for Acupuncture?
Step-by-Step Pre-Authorization Process:
- Your provider logs into Aetna’s portal or uses the electronic pre-certification tool.
- Submit your diagnosis, treatment plan, and supporting notes.
- Wait for written approval before starting care.
- Keep the authorization number for your claim.
Some HMO or EPO plans also require a referral from your primary care physician (PCP) before pre-authorization is approved.
Are There Limits to Acupuncture Coverage?
Yes.
Most Aetna plans impose annual visit caps (for example, 20 visits per year) and limit coverage to the specific conditions listed as medically necessary. Preventive, maintenance, or “wellness” acupuncture is generally excluded.
State mandates or employer-specific riders can modify these limits.
Are There Specific Providers I Need to See for Coverage?
Yes.
To qualify for in-network benefits, you must see licensed acupuncturists who are credentialed by Aetna and part of its provider network. You can search for participating practitioners through Aetna’s online provider directory.
Some plans restrict coverage to acupuncture performed by or under the supervision of a physician, while others allow independent licensed acupuncturists.
What Documentation is Needed for Coverage?
Aetna may require the following:
- A written referral or order from your doctor (if applicable)
- A treatment plan showing medical necessity
- Proof of provider licensure and credentialing
- Clinical progress notes documenting response to care
This documentation helps ensure that treatments meet the plan’s medical-necessity guidelines.
Can I Get Reimbursed for Out-of-Network Acupuncture?
Maybe.
PPO plans may reimburse a portion of out-of-network acupuncture costs, typically at a reduced rate.
HMO and EPO plans generally do not cover or reimburse out-of-network services.
Always confirm with Aetna or review your Explanation of Benefits (EOB).
Typical Billing Codes for Acupuncture
| Service | CPT Code | Description |
|---|---|---|
| Initial acupuncture (no e-stim) | 97810 | First 15 minutes |
| Subsequent acupuncture (no e-stim) | 97811 | Each additional 15 minutes |
| Initial electro-acupuncture | 97813 | First 15 minutes with electrical stimulation |
| Subsequent electro-acupuncture | 97814 | Each additional 15 minutes with electrical stimulation |
| Dry Needling | 20560 / 20561 | Not billed on the same day as acupuncture |
Only one “initial” code may be used per date of service.
Does Acupuncture Require a Referral from My PCP?
Possibly.
Some Aetna HMO or POS plans require a referral from your Primary Care Physician (PCP) to access acupuncture services. PPO plans typically allow direct access without referral. Always verify requirements before booking.
What Are the Typical Costs for Acupuncture Under Aetna?
| Cost Component | In-Network | Out-of-Network |
|---|---|---|
| Deductible | Applies unless waived | Always applies |
| Copay / Coinsurance | $20–$50 or 20% typical | 40–50% typical |
| Annual Visit Limit | 20 visits per year | Same limit applies |
| Balance Billing | Not applicable | Possible |
Your actual costs depend on your plan type, deductible status, and provider network.
What If My Claim Is Denied?
If your claim is denied:
- Request the denial reason and applicable policy reference (e.g., CPB 0135).
- Submit a written appeal within the timeframe listed on your EOB.
- Include:
- Your pre-authorization or referral approval number
- Relevant progress notes
- The covered indication (e.g., chronic headache, low back pain)
- Attach supporting medical documentation.
Aetna reviews appeals under both the policy bulletin and your specific plan’s benefits.
Where Can I Find More Information?
Visit Aetna.com and log in to your member portal to review your plan documents, confirm coverage, and locate in-network providers. You may also call Aetna customer service for clarification on coverage limits, required referrals, or pre-authorization steps.
Frequently Asked Questions
Will Aetna cover acupuncture for wellness or stress relief?
Usually no. Coverage is tied to the medical-necessity list in CPB 0135. Wellness or preventive visits are excluded.
Are electro-acupuncture treatments covered?
Yes, when billed under CPT 97813 or 97814 and meeting medical-necessity criteria outlined in Aetna CPB 0135.
Can I see an acupuncturist without a referral?
PPO plans generally allow direct access; HMO and EPO plans typically require a PCP referral and may also require pre-authorization.
What if my claim is denied?
Submit a written appeal with your benefit quote, pre-authorization reference, progress notes, and the CPB 0135 indication supporting medical necessity. The benefit plan ultimately governs coverage decisions.
Does Aetna cover dry needling?
Dry needling has separate CPT codes (20560, 20561) and coverage rules. It is not billed on the same day as acupuncture. Some plans exclude it entirely.
Where can I read Aetna’s policy?
Refer to Aetna Clinical Policy Bulletins 0135 (Acupuncture and Dry Needling) and 0388 (Complementary and Alternative Medicine) available on Aetna.com.
Sources
CMS Policy – Acupuncture for Chronic Low Back Pain (Medicare context)
Aetna Clinical Policy Bulletin 0135 – Acupuncture and Dry Needling
Aetna Clinical Policy Bulletin 0388 – Complementary & Alternative Medicine
Aetna Plan Overview – “Plan Governs” rule