Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for dry needling proceduresFindings:  The physician reviewer found that a systematic review and meta-analysis performed by Gattie and colleagues reviewed 13 studies to examine the short- and long-term effectiveness of dry needling delivered by a physical therapist for any musculoskeletal pain condition. They found that dry needling, when compared to control/sham treatment, provides a statistically significant effect on functional outcomes, but not when compared to other treatments. The authors concluded that very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period. They concluded that low-quality evidence suggests superior outcomes with dry needling for functional outcomes when compared to no treatment or sham needling. However, no difference in functional outcomes exists when compared to other physical therapy treatments. They concluded that evidence of long-term benefit of dry needling is currently lacking.Charles and colleagues conducted a 2019 systematic review of various manual therapy techniques, including dry cupping and dry needling for the treatment of myofascial pain and myofascial trigger points. The researchers looked at 23 studies that evaluated the benefits of dry needling, and they determined that the evidence for dry needling ranged from very low to moderate compared to control groups, sham interventions, or other treatments. They concluded that current studies suffered from limitations that included unclear methodologies, high risk for bias, inadequate blinding, no control group, and small sample sizes.In this case, the patient has chronic unspecified right hip pain. The submitted records reflect that the patient has been seen by physical therapy and treated with dry needling of trigger points for six sessions. The most recent systematic reviews conducted on the benefits of dry needling for musculoskeletal pain have shown, however, that there is weak evidence to support that dry needling is more beneficial than standard treatments. The Gattie study found that dry needling was superior to sham treatments but was not better than other standard of care treatments for musculoskeletal pain. They found no difference in objective functional outcomes between dry needling and standard treatments. Similarly, the 2019 meta-analysis confirmed that the current state of medical evidence supporting dry needling therapy over other therapeutic options was weak. The current studies were deemed inadequate due to poor methodologies and small sample sizes. Accordingly, the dry needling procedures at issue and going forward (for a total of twelve visits) were not, and are not, likely to have been and be more beneficial than any other available standard treatments for the patients medical condition. Findings:  Three out of three physician reviewers found that the dry needling procedures (CPT-20561) at issue and going forward (for a total of twelve visits) were not, and are not, likely to have been and be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue and requested services were not, and are not, likely to have been and be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in anesthesiology, with subspecialty certification in pain medicine, and are actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation, with subspecialty certification in pain medicine, and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.