Aetna considers a screening examination medically necessary for members who are being considered for admission into a chronic pain program.

1. Outpatient Pain Management Programs

   Aetna considers outpatient multidisciplinary pain management programs medically necessary when all of the following criteria are met:

   1. Referral for entry has been made by the primary care physician/attending physician; and
   2. Member has experienced chronic non-malignant pain (not cancer pain) for 6 months or more; and 
   3. The cause of the member's pain is unknown or attributable to a physical cause, i.e., not purely psychogenic in origin; and
   4. Member has failed conventional methods of treatment; and
   5. The member has undergone a mental health evaluation, and any primary psychiatric conditions have been treated, where indicated; and 
   6. Member's work or lifestyle has been significantly impaired due to chronic pain; and  
   7. If a surgical procedure or acute medical treatment is indicated, it has been performed prior to entry into the pain program.

   Aetna considers entry into an outpatient multidisciplinary chronic pain program of no proven benefit for members with any of the following contraindications:

   1. The member is unable to understand and carry out instructions; or
   2. The member exhibits aggressive and/or violent behavior; or
   3. The member exhibits imminently suicidal tendencies; or
   4. The member has unrealistic expectations of what can be accomplished from the program (i.e., member expects an immediate cure); or
   5. The member is medically unstable (e.g., due to uncontrollable high blood pressure, unstable congestive heart failure, or other medical conditions); or
   6. Member has previously failed an adequate multidisciplinary (e.g., Commission on Accreditation of Rehabilitation Facilities (CARF) accredited) chronic pain management program.

   Pain is considered chronic if it results from a chronic pathological process, has recurred periodically over months or years, or persists longer than expected after an illness or injury. Typically, pain is considered chronic if it has persisted for 6 months or more.

   Modality-oriented pain clinics and single disciplinary pain clinics are considered not medically necessary and inappropriate for comprehensive treatment of members with chronic pain.

   Note: Dependence or addiction to narcotics or other controlled substances is frequently part of the presentation of a member with chronic pain. Issues surrounding addiction, detoxification must be considered and evaluated prior to enrollment of a member into a pain management program.

2. Inpatient Pain Management Programs

   Aetna considers entry into an inpatient multidisciplinary pain management program for up to 21 days medically necessary when members meet the above criteria for entry into an outpatient pain management program as well as all of the following criteria:

   1. The member has major functional disabilities; and
   2. The pain has caused extensive disruption in family functioning; and
   3. The member needs extensive psychological or behavioral therapy; and
   4. The member needs temporary removal from a detrimental home situation to refocus their lives away from the pain.

   Note: Most inpatient chronic pain treatment programs require both medical and psychological evaluations before admission into the program. These evaluations should be performed on an outpatient basis; inpatient admission for these evaluations is considered not medically necessary. Participation in inpatient pain management programs for more than 21 days is subject to medical necessity review. Continued inpatient chronic pain treatment is considered not medically necessary for members who are not participating (e.g., failure to attend scheduled treatment sessions) in the program. An inpatient chronic pain management program is considered not medically necessary for persons who have failed a prior adequate multidisciplinary (e.g., CARF accredited) chronic pain management program.

   Note: Neuropsychological evaluation/testing is of no proven benefit for members with chronic pain being considered for treatment solely with narcotic pain medication.  See CPB 158 - Neuropsychological and Psychological Testing.

Pain is considered chronic if it persists longer than expected after an illness or injury, if it is associated with a chronic pathological process, or if it flares up periodically over months to years. Typically, pain is considered chronic if it has lasted 6 months or more.  Chronic pain may be caused by physical, psychological, and environmental factors.  Chronic pain can be categorized as malignant or non-malignant in etiology.  Chronic non-malignant pain encompasses many painful disorders such as back pain, migraine headaches, diabetic neuropathy, dental and orofacial pain, arthritic pain and pain due to musculoskeletal/rheumatic disorders.

Pain rehabilitation programs are a relatively new and innovative approach to the treatment of chronic, intractable non-malignant pain.  The goal of such programs is to give patients the tools to manage and control their pain and thereby improve their ability to function independently.  Chronic pain patients often have psychological problems that accompany or stem from physical pain. Hence, it is appropriate to include psychological treatment in the multidisciplinary approach to pain management.  However, patients whose pain results solely or primarily from psychiatric disorders rather than physical conditions generally cannot be successfully treated in a pain rehabilitation program.

Hospital-level pain rehabilitation programs use coordinated multidisciplinary teams to deliver, in a controlled environment, a concentrated program to modify pain behavior, which addresses physiological, psychological, and social factors that may contribute to the patient's pain.  Such programs generally include diagnostic testing, skilled nursing, psychotherapy, structured progressive withdrawal from pain medications, physical therapy and occupational therapy to restore physical fitness (mobility and endurance) to a maximal level within the constraints of a patient's physical disability, and the use of mechanical devices and/or activities to relieve pain or modify a patient's reaction to it (e.g., nerve stimulation, hydrotherapy, massage, ice, systemic muscle relaxation training, and diversional activities).  The program's day-to-day activities are under the general supervision and, as needed, direct supervision of a physician.

The literature suggests that generally up to three weeks of inpatient care may be required to modify pain behavior.  Any chronic pain rehabilitation that may be needed after that can usually be effectively provided on an outpatient basis.  Although many multi-disciplinary pain facilities have both inpatient and outpatient treatment programs, there is little evidence that inpatient programs are more effective than outpatient programs.  Outpatient pain rehabilitation programs frequently provide services in group settings, even though these services are being furnished pursuant to each patient's individualized plan of treatment.

There is sufficient evidence that multidisciplinary pain treatment clinics/centers are effective for the management of appropriately selected patients with chronic non-malignant pain.  Studies have shown that chronic pain patients who have completed these programs have lasting reductions in pain and psychological distress.  These studies have demonstrated improvements both in subjective ratings of pain and in objective measures such as reduced use of narcotic pain medications, increased rates of return-to-work, and decreased utilization of the health care system. A systematic evidence review by the Swedish Council on Technology Assessment in Health Care (SBU, 2006) concluded that "rehabilitation programs, referred to as multimodal rehabilitation (usually a combination of psychological interventions and physical activity, physical exercise or physical therapy) is that pain decreases more, a greater number of people return to work and sick leaves are shorter than with passive control and/or limited, separate interventions." The SBU assessment also found that multimodal rehabilitation improves long-term functional ability in fibromyalgia patients more effectively than passive control or limited, separate interventions.