Is Dry Needling Covered by Insurance?
In our previous blog, we reviewed 11 recent systematic reviews and meta-analyses (1-11). Each study supported that dry needling is effective for a wide variety of diagnoses, including spine-related pain (11), neck pain (2, 6, 11), spasticity (3), knee pain (7), lateral epicondylalgia (9), fibromyalgia (10), shoulder pain (4), general musculoskeletal conditions (5), tension-type, and cervicogenic, and migraine headaches (8). However, dry needling is still not covered by many US insurance companies, including CMS or Medicare, who readily claim that dry needling would be investigational or experimental despite the overwhelming evidence to the contrary!
Commercial insurer Anthem maintains that dry needling is “not medically necessary.” The change was announced in conjunction with the release of the latest Clinical Appropriateness Guidelines for Rehabilitation, produced by American Imaging Management Specialty Health, or AIM, Anthem’s utilization management arm.
Dry needling by a trained practitioner is considered medically necessary in ANY of the following clinical scenarios for up to a total of 3 sessions:
● Appendicular skeleton: myofascial trigger point-related pain of shoulder region, lateral elbow, trochanteric bursitis, or plantar heel
● Axial skeleton: myofascial trigger point-related cervical and thoracolumbar pain
● Headache, cervicogenic and tension-type only
● Myofascial pain syndrome
● Temporomandibular joint disorders Note:
Dry needling is considered not medically necessary for all other clinical scenarios (see Exclusions). For all clinical scenarios, acceptable indications are limited to a) pain relief to allow better tolerance of the broader physical or occupational therapy program in cases wherein pain has been demonstrated to have impeded a patient’s ability to effectively participate with the use of conventional therapies, b) pain relief to avoid or reduce otherwise likely use of analgesic medication, and c) reduction of disability. Additionally, for headaches, reduction of headache frequency, and/or duration are also acceptable indications. The specific indication(s) for this intervention must be clearly documented and supported by the clinical notes.
Insurance company ASH/Cigna has taken it even further by requiring that
“Patients should be informed in writing that the evidence for dry needling’s effectiveness is inconclusive and the service is unproven and therefore not a covered service. All procedures. including unproven procedures, need to be documented in the patient’s medical record along with documentation of the discussion about the unproven nature of the procedure” (17).
Its “Clinical Practice Guideline on Dry Needling Policy” dates back to 2014!
Looking at what drives commercial or private-funded insurance companies, their decision not to cover dry needling is indeed rather mesmerizing. Considering that in 2019, the average annual premium for a family was over $20,000 and over $7,100 for individual coverage, according to a survey by the Henry J. Kaiser Family Foundation (12). The average premium costs have increased by 22% over the past five years and by 54% over the past ten years. An insurance company is in the business of making money. Their subscribers, including employers and individual policyholders, provide the insurance company with underwriting capital. The money collected from all those customers is used to pay for medical care in the form of claims and to cover operating costs. You would think that with the kind of premiums insurance companies are collecting, they would have plenty of money to cover all medical claims. Think again.
The Revenue Model of Insurance Companies
Of course, the less money an insurance company pays out, the greater their profit. Therefore, insurance companies have figured out how to reduce medical claims payments. Did you know that 82% of covered employees have a general annual deductible that must be met before most services are paid for by the insurance company (12)? That average annual deductible has increased by 36% over the last five years and 100% over the last ten years and can be as much as $2,000 or more. To keep physicians and hospitals at bay, insurance companies have arranged that whatever they will not cover is paid for by individuals in the form of co-payments on top of the annual premiums.
Any money that is not paid out for claims or used for the costs of doing business is invested in bonds, stocks, real estate, and other assets, not to mention executive salaries and compensation. As the President, Chief Executive Officer, and Director of Cigna, the total compensation of David Cordani at Cigna is $19,303,000. There is one executive at Cigna getting paid more, with Timothy Wentworth having the highest compensation of $23,544,300. Investments make up most of an insurance company’s income, making insurance companies attractive to shareholders.
How Insurance Passes Costs Onto the Practitioner and Patient
It is in the best interest of an insurance company to cover at least as possible, shifting the financial responsibility to individual patients. When physicians are not satisfied with the money paid by insurance companies supplemented by patients’ co-payments, they may decide to set up boutique or concierge practices and charge patients annual fees, in addition to collecting co-payments and insurance money, which gives patients the privilege to set up appointments with the physician. Some physical therapy practices follow in these footsteps, but this is not an option for the majority.
How Much Does Dry Needling Cost?
Back to dry needling. Clearly, the best scenario from the insurance company’s point of view is to collect premiums and to cover as little as possible. Perhaps that explains why many companies completely deny paying for dry needling. Even though there are two CPT codes for dry needling – 20560 Needle insertion(s) without injection(s), 1 or 2 muscle(s) and 20561 Needle insertion(s) without injection(s), 3 or more muscle(s) – many physical therapists are reluctant to use these codes since likely, they will not be reimbursed. Some therapists charge patients a dry needling fee, but others appear to use other CPT codes to get paid, such as a manual therapy code (97140) or a neuromuscular education code (97112) that usually are covered by insurance companies.
A question arises: Would paying for dry needling be more cost-effective? Several studies demonstrate that by including dry needling into a comprehensive treatment program, the costs go down!
Dry Needling Costs and Evaluations of Cost-Effectiveness
Dry Needling and Exercise for Subacromial Pain Syndrome
In this randomized clinical trial (13), 50 patients diagnosed with subacromial pain syndrome were randomly assigned to an exercise alone or exercise plus trigger point dry needling group. Subjects in both groups performed exercises for the rotator cuff muscles two times per day for five weeks. Patients in the trigger point dry needling group also received dry needling during the second and fourth sessions.
Over a one-year follow-up, patients in the exercise-only group had more visits to their physicians and received a greater number of other treatments (P < 0.001). The costs to society measured as days of absenteeism from their jobs were greater in the exercise-only group, while the incremental cost per quality-adjusted life-year (QALY) ratios showed more significant benefit for the trigger point dry needling group.
In other words, when an insurance company would consider the total costs related to the diagnosis of subacromial pain syndrome, they may find that not having to pay for the extra visits to the patients’ physicians may significantly offset the perceived costs of dry needling by a physical therapist!
Dry Needling for Plantar Heel Pain
In this study (14), the costs of dry needing were compared to the costs of percutaneous needle electrolysis, which is a dry needling approach targeting a tendon with a needle combined with an application of galvanic stimulation. A total of 102 patients with an average age of 48 years were included in the final economic analysis. While dry needling was less expensive than percutaneous electrolysis, the quality-of-life indicators were actually in favor of percutaneous electrolysis. Although this study did not compare dry needling to other more common interventions in the US, the study still found dry needling to be cost-effective.
Dry Needling in the Rehabilitation of Patients With Stroke
Although this paper is not yet in print, the results are encouraging. In this Spanish study (15), 80 patients (aged 73.2 ± 13.3 years) with a stroke in the subacute stage of recovery were allocated to either a standard rehabilitation or a rehabilitation plus dry needling group. All patients were seen five days per week for a total of eight weeks. Dry needling was included in six treatment sessions (weeks 1, 2, 3, 4, 6, and 8). The researchers used the Modified Modified Ashworth Scale (MMAS) and the values of the EuroQol-5 dimensions questionnaire (EQ-5D-5L) as the outcome measures.
While there were no direct financial benefits to adding dry needling to the standard rehabilitation program, the results of the MMAS spoke volumes. An average of 92% of patients responded favorably at 4 weeks versus 18% in the control group and 70% versus 17% at 8 weeks. From an economic perspective, the cost per responder was most inexpensive for the group receiving dry needling in all cases. The costs per responder of the control group were significantly higher than for the dry needling group. Four weeks of dry needling appeared to have greater odds of being cost-effective than physical therapy alone, which implies that insurance companies would save money by encouraging physical therapists to incorporate dry needling into the rehabilitation programs of patients with a stroke.
Upper Extremity Dry Needling for Chronic Stroke
In this study (16), 23 patients (aged 60.87 ± 15.16 years (mean ± SD; 61% male) with chronic stroke were randomly assigned to an intervention group and a sham group. Subjects in the intervention group received a single session of dry needling targeting the biceps brachii, brachialis, flexor digitorum superficialis, and profundus, extensor digitorum, adductor pollicis, and triceps brachii muscles with the muscles in a submaximal stretch position. Subjects in the sham group received a sham intervention with the needles placed superficially at the skin level. As in the previous study, the outcome measures were the Modified Ashworth Scale (MMAS) and values of the EuroQol-5 dimensions questionnaire (EQ-5D-5L).
The researchers concluded that “dry needling is an affordable alternative with good results in the cost‐effectiveness analysis—both immediately, and after two weeks of treatment, compared to sham dry needling in persons with chronic stroke.”
In the end, each insurance company will decide whether reimbursing physical therapists for CPT codes 20560 and 20561 is cost beneficial. Insurance companies may not be convinced by the data from systematic reviews and meta-analyses because the interests of their shareholders may be more persuasive, but the cost analyses of the studies presented in this blog may have some impact even when they were conducted in Spain. Considering that healthcare costs are much higher in the US, the cost-benefit ratios might be even more striking.
- Griswold D, Wilhelm M, Donaldson M, Learman K, Cleland J. The effectiveness of superficial versus deep dry needling or acupuncture for reducing pain and disability in individuals with spine-related painful conditions: a systematic review with meta-analysis. J Manual Manipulative Ther. 2019;27(3):128-140.
- Fernández-De-Las-Peñas C, Plaza-Manzano G, Sanchez-Infante J, et al. Is Dry Needling Effective When Combined with Other Therapies for Myofascial Trigger Points Associated with Neck Pain Symptoms? A Systematic Review and Meta-Analysis. Pain Research & Management :. 2021;2021:8836427.
- Fernández-de-Las-Peñas C, Pérez-Bellmunt A, Llurda-Almuzara L, Plaza-Manzano G, De-la-Llave-Rincón AI, Navarro-Santana MJ. Is Dry Needling Effective for the Management of Spasticity, Pain, and Motor Function in Post-Stroke Patients? A Systematic Review and Meta-Analysis. Pain Med. 2021;22(1):131-141.
- Navarro-Santana MJ, Gómez-Chiguano GF, Cleland JA, Arias-Buría JL, Fernández-de-las-Peñas C, Plaza-Manzano G. Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis. Phys Ther. 2020;101(2).
- Sánchez-Infante J, Navarro-Santana MJ, Bravo-Sánchez A, Jiménez-Diaz F, Abián-Vicén J. Is Dry Needling Applied by Physical Therapists Effective for Pain in Musculoskeletal Conditions? A Systematic Review and Meta-Analysis. Phys Ther. 2021.
- Navarro-Santana MJ, Sanchez-Infante J, Fernández-de-Las-Peñas C, Cleland JA, Martín-Casas P, Plaza-Manzano G. Effectiveness of Dry Needling for Myofascial Trigger Points Associated with Neck Pain Symptoms: An Updated Systematic Review and Meta-Analysis. J Clin Med. 2020;9(10).
- Rahou-El-Bachiri Y, Navarro-Santana MJ, Gómez-Chiguano GF, et al. Effects of Trigger Point Dry Needling for the Management of Knee Pain Syndromes: A Systematic Review and Meta-Analysis. J Clin Med. 2020;9(7).
- Pourahmadi M, Dommerholt J, Fernández-de-Las-Peñas C, et al. Dry Needling for the Treatment Of Tension-Type, Cervicogenic, or Migraine Headaches: a Systematic Review and Meta-Analysis. Phys Ther. 2021.
- Navarro-Santana MJ, Sanchez-Infante J, Gomez-Chiguano GF, et al. Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis. Clin Rehabil. 2020;34(11):1327-1340.
- Sarmiento-Hernandez I, Perez-Marin MLA, Nunez-Nagy S, Pecos-Martin D, Gallego-Izquierdo T, Sosa-Reina MD. Effectiveness of Invasive Techniques in Patients with Fibromyalgia: Systematic Review and Meta-Analysis. Pain Med. 2020;21(12):3499-3511.
- Lew J, Kim J, Nair P. Comparison of dry needling and trigger point manual therapy in patients with neck and upper back myofascial pain syndrome: a systematic review and meta-analysis. Journal of Manual & Manipulative Therapy. 2020:1-11.
- Kaiser Family Foundation Employer Health Benefits Survey, Henry J. Kaiser Family Foundation, San Francisco, 2019
- Arias-Buria JL, Martin-Saborido C, Cleland J, Koppenhaver SL, Plaza-Manzano G, Fernandez-de-Las-Penas C. Cost-effectiveness Evaluation of the Inclusion of Dry Needling into an Exercise Program for Subacromial Pain Syndrome: Evidence from a Randomized Clinical Trial. Pain Med. 2018;19(12):2336-2347
- Fernández D, Al-Boloushi Z, Bellosta-López P, Herrero P, Gómez M, Calvo S. Cost-Effectiveness of Two Dry Needling Interventions for Plantar Heel Pain: A Secondary Analysis of an RCT. Int J Environ Res Public Health. Feb 12 2021;18(4) doi:10.3390/ijerph18041777
- Fernández Sanchis D, Cuenca Zaldívar JN, Calvo S, Herrero P, Gómez Barrera M. Cost-effectiveness of upper extremity dry needling in the rehabilitation of patients with stroke. Acupunct Med. Dec 2 2021:9645284211055750. doi:10.1177/09645284211055750
- Fernández-Sanchis D, Brandín-de la Cruz N, Jiménez-Sánchez C, Gil-Calvo, M, Herrero, P, Calvo, S. Cost-Effectiveness of Upper Extremity Dry Needling in Chronic Stroke. Healthcare 2022, 10, 160. https://doi.org/10.3390/healthcare10010160
- Inside ASH, November/December 2021, American Specialty Health.