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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that for services performed on or after January 21, 2020, Medicare will now provide limited
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage,
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause,
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may
be provided by a physician in accordance with state requirements, or by physician assistants, nurse
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements.
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician,
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage
Determinations Manual, Section 30.3.3.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:
For the purpose of this benefit, chronic low back pain is defined as: pain lasting 12 weeks or longer;
nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory,
infectious, etc. disease); pain not associated with surgery; and not associated with pregnancy. An additional
eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture
treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is
regressing. Physicians (as defined in 1861(r)(1) of the Social Security Act (the Act) may furnish acupuncture in
accordance with applicable state requirements. Physician assistants (PAs), nurse practitioners (NPs)/clinical
nurse specialists (CNSs) (as identified in 1861(aa)(5) of the Act), and auxiliary personnel may furnish
acupuncture if they meet all applicable state requirements and have a masters or doctoral level degree in
acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture
and Oriental Medicine (ACAOM); and a current, full, active, and unrestricted license to practice
acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of
Columbia. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a
physician, PA, or NP/CNS required by our regulations at 42 CFR  410.26 and 410.27. You can see this
starting on page 63 of the Plans 2022 Evidence of Coverage.