2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 77 Services that are covered for you What you must pay when you get these services in-network and out-of-network Acupuncture for chronic low back pain $15 copayment for each Covered services include: Medicare-covered visit. Up to 12 visits in 90 days performed by, or under the You pay these amounts until supervision of a physician (or other medical provider as you reach the out-of-pocket described below) are covered for Medicare beneficiaries maximum. under the following circumstances: For the purpose of this benefit, chronic low back pain is defined as: · Lasting 12 weeks or longer; · nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious disease, etc.); · not associated with surgery; and · not associated with pregnancy. An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is regressing. Generally, Medicare-covered acupuncture services are not covered when provided by an acupuncturist or chiropractor. Provider Requirements: Physicians (as defined in 1861(r)(1) of the Social Security Act (the Act) may furnish acupuncture in accordance with applicable state requirements. Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs) (as identified in 1861(aa)(5) of the Act), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have: · a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the