Prior Authorization Request (Acupuncture Services)

Cover Sheet

Document Title: Prior Authorization Request (Acupuncture Services)

Request Type: [Initial / Continuation / Appeal]

Urgency: [Routine / Expedited]

Date of Request: [Date]

Requested Service Dates: [Start date] through [Anticipated end date]

Patient Name: [Full name]

Date of Birth: [MM/DD/YYYY]

Member ID: [ID or Unknown]

Group Number: [Group number or Unknown]

Payer Name: [Payer]

Plan Type: [Commercial / Medicare Advantage / Medicaid / Workers' Comp]

Prior Authorization Number: [PA number] (Include only for Continuation or Appeal)

Rendering Provider: [Name]

Credentials: [Credentials]

NPI: [NPI]

Practice/Facility Name: [Name]

Referring Provider: [Name and credentials] (Include only if different from rendering provider)

Requested Services

CPT Code	Description	Units per Visit	Total Visits Requested	Date Range	Diagnosis Codes (ICD-10-CM)
[CPT code]	[Procedure description]	[Units/visit]	[Total visits]	[From–To]	[ICD-10-CM codes at highest specificity]

(Add additional rows as needed for each requested procedure code)

Primary Diagnosis (ICD-10-CM): [Code – Description]

Clinical Indication: [One sentence stating condition, duration, and functional impact despite conservative care, using payer coverage language]

Adjunct modalities without standalone coverage: [Not requested / Requested as bundled adjunct (not separately billed) / Requested as separately billed — rationale] (Include only if cupping or similar modalities are being requested)

Coverage Criteria Alignment

• Duration criterion: [Meets / Does not meet] — [Onset date, duration in weeks]
• Nonspecific qualifier: [Meets / Not applicable] — [Confirmation that pain is not attributable to specific pathology requiring other treatment]
• Exclusions addressed: Pregnancy [No / Yes / Unknown]; Post-surgical exclusion window [Not applicable / Outside window / Within window]; Red flags for systemic/inflammatory/infectious/malignant etiology [None identified / Addressed as follows]
• Medical necessity statement: [Statement that requested services are reasonable and necessary with measurable functional goals]

Medicare NCD 30.3.3 Attestation (Chronic Low Back Pain)

(Include this subsection only if Plan Type is Medicare Advantage or Medicare and condition is chronic low back pain)

• Chronicity: [Meets / Does not meet] — Low back pain duration ≥12 weeks; onset [Date]
• Nonspecific: [Meets / Does not meet] — Not associated with pregnancy, surgery, cancer, infectious, inflammatory, or structural causes requiring alternative treatment
• Anatomical scope: [Meets / Does not meet] — Pain localized to lumbar region with or without referral
• Treatment course: [Initial 12 visits requested / Continuation based on documented response]

Clinical Summary

[Chief complaint and primary symptom driver]

[Onset date, clinical course, and reason care is needed now]

[Prior evaluations: imaging, specialist consults, key findings with dates]

[Pertinent comorbidities affecting treatment selection and current treatment status]

"[Brief patient quote]" — [Clinical interpretation] (Include only if helpful for conveying functional impact)

• ADL limitations: [Walking distance, standing/sitting tolerance, lifting, sleep, self-care impacts]
• Work/role limitations: [Missed days, restricted duty, essential functions impacted]
• Mobility/safety: [Fall risk, gait impairment, balance concerns] (Include only if applicable)
• Patient goals: [Concise, measurable goals tied to function]

Prior Conservative Management

Intervention	Dates	Dose/Visits	Response	Reason Stopped/Status
Self-management (home exercise, ergonomics, heat/ice)	[From–To]	[Frequency/duration]	[Objective response]	[Continues / Completed / Ineffective / Intolerant]
Formal rehab (PT/OT/chiropractic/massage)	[From–To]	[Visits and frequency]	[Measured outcomes]	[Discharged / Ongoing / Paused — reason]
Medications (NSAIDs, muscle relaxants, topicals, other)	[From–To]	[Dose/regimen]	[Effectiveness and side effects]	[Stopped — reason / Contraindicated / Ongoing]
Procedures/injections	[Date(s)]	[Type and number]	[Response]	[Completed / Planned / Not applicable]

(If conservative therapy was not attempted, document reason: contraindication, access barrier, or guideline-supported initial acupuncture. If dates are approximate, note verification source. Do not omit unavailable data—mark as Unknown with plan to obtain.)

Baseline Measures

Measure	Date	Value	Interpretation
Pain intensity (NRS 0–10 or VAS)	[Date]	[Score]	[Baseline severity]
Functional outcome (ODI/RMDQ or PROMIS PI/PF)	[Date]	[Score]	[Baseline disability level]

(If baseline functional measure not yet available, state plan to capture at first visit and note this limitation)

Physical examination: [Neurologic status, ROM limitations, provocative tests, gait assessment]

Imaging/diagnostic studies: [Study type, date, key results ruling out exclusionary pathology] (Include only if applicable)

Proposed Treatment Plan

Plan Overview:

• Requested frequency: [Frequency per week]
• Duration: [Number of weeks]
• Total visits requested: [Number] — [Rationale tied to baseline severity and goals]
• Re-evaluation schedule: [Reassessment points with objective measures]
• Time-limited trial: [Yes / No] — contingent on documented improvement as defined below

Modalities and Rationale:

• Manual acupuncture: [Rationale specific to condition and patient factors]
• Electroacupuncture: [Indication and why manual acupuncture alone is insufficient] (Include only if requested)
• Cupping or other adjuncts: [Clinical rationale] — [Bundled adjunct / Separately billed with rationale] (Include only if requested)

Treatment Details: [Body region focus; session duration; safety procedures including single-use sterile needles and adverse event monitoring; electroacupuncture parameters if applicable]

Goals and Continuation Criteria

Goal	Metric	Baseline	Target	Timeframe	Decision Threshold
Reduce pain intensity	NRS/VAS	[Baseline score]	[Target reduction]	[Weeks]	[Threshold for continuation]
Improve function	[ODI/RMDQ or PROMIS]	[Baseline score]	[Target improvement]	[Weeks]	[Threshold for continuation]
Functional task goal	[Task-specific metric]	[Baseline ability]	[Target ability]	[Timeframe]	[Threshold]

Continuation criteria: [Specific improvement thresholds required to justify additional sessions beyond initial block]

Discontinuation criteria: [Stop rules: no objective improvement by specified visit, regression in function, adverse events, or emerging contraindications]

Safety Screening

• Bleeding risk/anticoagulant status: [None / Present — details / Unknown]
• Pregnancy status: [No / Yes / Unknown] (Include if coverage-relevant)
• Implanted electrical devices: [None / Present — device type and clearance status] (Include if electroacupuncture planned)
• Skin integrity/infection risk at treatment sites: [Intact / Concerns — details]
• Prior adverse reactions to acupuncture: [None / Yes — details]
• Informed consent documented: [Yes / No — plan to obtain]

Supporting Documentation

• Recent clinical visit note(s): [Attached / Pending / Not available] — [Date(s)]
• PT/OT records or discharge summary: [Attached / Pending / Not applicable] — [Date(s)]
• Medication history: [Attached / Pending] — [Source/date]
• Imaging reports: [Attached / Not applicable] — [Study type/date]
• Prior acupuncture records with response data: [Attached / Not applicable] — [Date range] (For continuation requests)
• Outcome measure forms: [Attached / Pending] — [Tool/date]

Attestation

Provider Signature: _______________________________

Date/Time: [MM/DD/YYYY HH:MM]

Credentials: [Credentials]

Licensure State: [State]

NPI: [NPI]

"I certify that the above information is accurate and complete, and supports medical necessity for the requested services."

Amendment/Addendum

(Include only if this document amends a prior submission)

This document is an amendment to submission dated [Original submission date]. Reason for amendment: [Reason].