Lab-on-a-chip (LOC) technology has gained primary attention in the past decade, where label-free biosensors and microfluidic actuation platforms are integrated to realize such LOC devices. Among the multitude of technologies that enables the successful integration of these two features, the piezoelectric acoustic wave method is best suited for handling biological samples due to biocompatibility, label-free and non-invasive properties. In this review paper, we present a study on the use of acoustic waves generated by piezoelectric materials in the area of label-free biosensors and microfluidic actuation towards the realization of LOC and POC devices. The categorization of acoustic wave technology into the bulk acoustic wave and surface acoustic wave has been considered with the inclusion of biological sample sensing and manipulation applications. This paper presents an approach with a comprehensive study on the fundamental operating principles of acoustic waves in biosensing and microfluidic actuation, acoustic wave modes suitable for sensing and actuation, piezoelectric materials used for acoustic wave generation, fabrication methods, and challenges in the use of acoustic wave modes in biosensing. Recent developments in the past decade, in various sensing potentialities of acoustic waves in a myriad of applications, including sensing of proteins, disease biomarkers, DNA, pathogenic microorganisms, acoustofluidic manipulation, and the sorting of biological samples such as cells, have been given primary focus. An insight into the future perspectives of real-time, label-free, and portable LOC devices utilizing acoustic waves is also presented. The developments in the field of thin-film piezoelectric materials, with the possibility of integrating sensing and actuation on a single platform utilizing the reversible property of smart piezoelectric materials, provide a step forward in the realization of monolithic integrated LOC and POC devices. Finally, the present paper highlights the key benefits and challenges in terms of commercialization, in the field of acoustic wave-based biosensors and actuation platforms.