United Health Care and CIGNA have begun using Medically Unlikely Edits (MUE) to limit acupuncture to 3 sets per visit regardless of manual or electrical.
n this policy, CMS Medically Unlikely Edits (MUE) it indicates “In accordance with the code descriptions and/or the Centers for Medicare and Medicaid Services (CMS) guidelines and CMS Medicaid National Correct Coding Initiative (NCCI) established Medically Unlikely Edits (MUE) values, the maximum units of Acupuncture services allowed per date of service”.
The document that policy is referencing specifically indicates the limits of one initial set and up to two additional sets regardless of manual or electrical acupuncture. An MUE is defined for certain CPT codes the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. The rationale for the limit to acupuncture is based upon code description, CPT instructions, and nature of service. It is specifically not indicated as a CMS policy or related to Medicare reimbursement.
An MUE may be appealed, when a claim denial is based on these edits if there is adequate documentation of medical necessity for the reported units. I have had many providers for VA Choice claims request and receive additional acupuncture sets per visit allowance.
With an appeal, the provider would require information on the specific need for sets exceeding the MUE with a rationale and specific goals, hopefully under some evidenced-based guidelines.
While 2-3 sets are the average use of 4 or more will require an appeal for these two payers and others may follow.
Note the VA Choice plan for Triwest has been limiting acupuncture to two sets since later 2018, though a provider may request more.