The list below may change at any time. This list is provided for informational purposes only, and does not guarantee that your policy covers acupuncture. Please contact the UPMC Health Plan for specifics on your policy, including any deductibles, copays or co-insurance that may apply.
For acupuncture coverage to apply, the following criteria must be met:
Diagnosis Codes:
M54.40-M54.42 Lumbago with sciatica
M54.50-M54.59 Low back pain
Diagnosis Codes:
G43.001-G43.019 Migraine without aura
G43.101-G43.119 Migraine with aura
G43.401-G43.419 Hemiplegic migraine
G43.501-G43.519 Persistent migraine aura without cerebral infarction
G43.601-G43.619 Persistent migraine aura with cerebral infarction
G43.701-G43.719 Chronic migraine without aura
G43.801-G43.839 Other migraine
G43.901-G43.919 Migraine, unspecified
G43.E01 Chronic migraine with aura, not intractable, with status
migrainosus
G43.E09 Chronic migraine with aura, not intractable, without status
migrainosus
G43.E11 Chronic migraine with aura, intractable, with status migrainosus
G43.E19 Chronic migraine with aura, intractable, without status migrainosus
Diagnosis Codes:
M17.0-M17.9 Osteoarthritis of knee
Diagnosis Codes:
M54.2 Cervicalgia
Diagnosis Codes:
O21.0 Mild hyperemesis gravidarum
O21.1 Hyperemesis gravidarum with metabolic disturbance
O21.2 Late vomiting of pregnancy
O21.8 Other vomiting complicating pregnancy
O21.9 Vomiting of pregnancy, unspecified
R11.0 Nausea
R11.10 Vomiting, unspecified
R11.11 Vomiting without nausea
R11.12 Projectile vomiting
R11.2 Nausea with vomiting, unspecified
T45.1X5A-T45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs
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