CLINIC PROCEEDINGS 1142 Mayo Clin Proc. n October 2013;88(10):1141-1146 n ents (eg, hospitalization, permanent disability, or death) were reported in relation to acupuncture therapy, and the rate of underlying minor adverse events (eg, nausea, fainting, prolonged aggravation of existing symptoms, and psychological or emotional reaction) was reported to be between 0 and 1.1 per 10,000 treatments.17 Acupuncture involves puncturing the skin, and therefore slight bruising, bleeding, or soreness at the acupuncture site may occur because of needle penetration through capillaries. More serious adverse effects, such as a vasovagal response with a decrease in blood pressure and syncope, have been reported. Infections may occur at the needle site from the use of nonsterile needles. When herbs are burned too close to the skin, burn injuries can result around the needle site. Most patients communicate a sense of relaxation and well-being after a treatment. Acupuncture is generally considered safe for persons with bleeding disorders or taking anticoagulants. However, it is important for the patient to advise the practitioner of these facts so the practitioner can use vigilance in selecting insertion points. Acupuncture during pregnancy is a matter of continued debate. Certain acupuncture points are contraindicated because they may induce uterine contractions and premature labor. WHAT CAN PATIENTS EXPECT AS PART OF THEIR TREATMENT? Every acupuncture practitioner has a distinct style and approach. Generally, a treatment session involves an initial visit that consists of a patient questionnaire, verbal inquiry, and a focused physical examination. With the use of this information, a diagnosis and a therapy plan are established. Patients are usually surprised to learn that acupuncture is associated with minimal or no discomfort. Some patients feel a slight pinch as the needles are inserted, but many feel no pain at all. As the needles are advanced to the indicated depth, several sensations may occur, including pressure, heaviness, and warmth at the needle site. After the insertion of acupuncture needles, stimulation of the site of these needle insertions often is necessary. The needle may be stimulated manually with gentle twisting back and forth and with slight movements up and down. Heat also may be used in various ways to stimulate the needle point, including moxibustion, in which an herb is burned near the acupuncture point or on the needle itself. Another technique of using heat is to include an indirect heat source, such as an infrared heat lamp, projected over the area of needle points. A low-intensity electric current may be connected to a pair of needles to provide another form of needle stimulation. Treatments can last from 30 minutes to an hour, with the needles being retained for 15 to 20 minutes. Although many patients may have symptom improvement with the first acupuncture treatment, other patients may not see improvement until they have completed several treatments. Because acupuncture is individually tailored to each patient and the patient’s medical condition, the frequency and duration of therapy differ. In general, most conditions can be treated with 6 to 12 sessions of acupuncture. The patient may need to return periodically for maintenance treatments to maintain longterm benefits from acupuncture. IS ACUPUNCTURE COVERED BY INSURANCE? Currently, Medicare does not cover acupuncture. Congressman Maurice Hinchey introduced the Federal Acupuncture Coverage Act in 1993 to add acupuncture as a benefit covered under both Medicare Part B and the Federal Employees Health Benefits program.18Congressional support for the bill was modest initially, FIGURE. Comparison of acupuncture needles with a 20-gauge hypodermic needle. Coin shown for indication of needle sizes. ACUPUNCTURE Mayo Clin Proc. n October 2013;88(10):1141-1146 n http://dx.doi.org/10.1016/j.mayocp.2013.06.009 www.mayoclinicproceedings.org 1143 but it has increased steadily with increased public acceptance and use of acupuncture. Most recently, the Federal Acupuncture Coverage Act of 2011 was introduced in the House of Representatives, but it was not enacted.19 Many commercial insurance providers cover acupuncture treatments, either partially or totally, but they may place limits on the total number of treatments. Patients should be advised to check their eligibility of coverage before receiving treatment. If the insurance provider covers acupuncture, several questions should be asked to determine eligibility and coverage: d How many treatments are covered? d Who must provide the acupuncture services? d Do I need a physician referral? d What conditions are covered for acupuncture? d What are my out-of-pocket costs? WHO PROVIDES ACUPUNCTURE TREATMENTS? Nonphysician, licensed acupuncturists provide most acupuncture treatments in the United States. Although formal training programs differ from state to state, the National Certification Commission for Acupuncture and Oriental Medicine has developed rigorous certification criteria and examination requirements for licensed acupuncturists. The