Aetna considers a screening examination medically necessary for members who are being considered for admission into a chronic pain program.
Outpatient Pain Management Programs
Aetna considers outpatient multi-disciplinary pain management programs medically necessary when all of the following criteria are met:
If a surgical procedure or acute medical treatment is indicated, it has been performed prior to entry into the pain program; and
Member has experienced chronic non-malignant pain (not cancer pain) for 6 months or more; and
Member has failed conventional methods of treatment; and
Member has undergone a mental health evaluation, and any primary psychiatric conditions have been treated, where indicated; and
Member's work or lifestyle has been significantly impaired due to chronic pain; and
Referral for entry has been made by the primary care physician/attending physician; and
The cause of the member's pain is unknown or attributable to a physical cause, i.e., not purely psychogenic in origin.
Aetna considers entry into an outpatient multi-disciplinary chronic pain program of no proven benefit for members with any of the following contraindications:
Member exhibits aggressive and/or violent behavior; or
Member exhibits imminently suicidal tendencies; or
Member has previously failed an adequate multi-disciplinary (e.g., Commission on Accreditation of Rehabilitation Facilities (CARF) accredited) chronic pain management program; or
Member has unrealistic expectations of what can be accomplished from the program (i.e., member expects an immediate cure); or
Member is medically unstable (e.g., due to uncontrollable high blood pressure, unstable congestive heart failure, or other medical conditions); or
Member is unable to understand and carry out instructions.
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.
Inpatient Pain Management Programs
Aetna considers entry into an inpatient multi-disciplinary 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:
Member has major functional disabilities; and
Member needs extensive psychological or behavioral therapy; and
Member needs temporary removal from a detrimental home situation to re-focus their lives away from the pain; and
The pain has caused extensive disruption in family functioning.
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 multi-disciplinary (e.g., CARF accredited) chronic pain management program.
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. It 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 musculo-skeletal/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. Comprehensive treatment of chronic pain must address both physical and psychological aspects; thus, inter-disciplinary approaches to pain management involve medical management, physical therapy, occupational therapy, biofeedback, vocational and recreational therapy, and psychological counseling. Collaboration among therapists, psychologists, and other supportive resources is important to delivering effective pain treatments.
Chronic pain patients often have psychological problems that accompany or stem from physical pain. Hence, it is appropriate to include psychological treatment in the multi-disciplinary approach to pain management. However, patients whose pain results solely or primarily from psychiatric disorders rather than physical conditions generally can not be successfully treated in a pain rehabilitation program.
Hospital-level pain rehabilitation programs use coordinated multi-disciplinary 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 3 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 multi-disciplinary 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 multi-modal rehabilitation improves long-term functional ability in fibromyalgia patients more effectively than passive control or limited, separate interventions.
An assessment of multidisciplinary pain programs for chronic non-cancer pain, preparted for the Agency for Healthcare Research and Quality (Jeffery, et al, 2011) found that multidisciplinary pain programs have been extensively documented in the standard medical literature. The 183 papers considered in the AHRQ assessment followed a biopsychosocial model of chronic pain, including treatment components in each of four areas: medical, behavioral, physical reconditioning, and education. Most of the studies considered in the AHRQ assessment were observational before-after designs. Although several different clinical conditions were studied, 90 percent of the studies included chronic back pain, the most frequent condition addressed in the literature. The report noted that differences were apparent between studies based in the United States and those in Europe; recent European studies were more likely than U.S. studies to include inpatient delivery of multidisciplinary pain program treatment. Declining access to multidisciplinary pain program treatment in the United States is highlighted as a key issue faced by those in the community of chronic pain sufferers and researchers.
Heutink et al (2012) evaluated a multi-disciplinary cognitive behavioral treatment program for persons with chronic neuropathic pain after spinal cord injury (SCI). The intervention consisted of educational, cognitive, and behavioral elements. A total of 61 people were randomized to either the intervention group or the waiting list control group in 4 Dutch rehabilitation centers. Primary outcomes were pain intensity and pain-related disability (Chronic Pain Grade questionnaire), and secondary outcomes were mood (Hospital Anxiety and Depression Scale), participation in activities (Utrecht Activities List), and life satisfaction (Life Satisfaction Questionnaire). Measurements were performed at baseline, and at 3, and 6 months follow-up. The primary statistical technique was random co-efficient analysis. The analyses showed significant changes over time on both primary (t1 - t2), and 2 out of 4 secondary outcomes (both t1-t2 and t1-t3). Significant intervention effects (Time*Group interactions) were found for anxiety and participation in activities, but not for the primary outcomes. Subsequent paired-t tests showed significant changes in the intervention group that were not seen in the control group: decrease of pain intensity, pain-related disability, anxiety, and increase of participation in activities. The authors concluded that these findings implied that a multi-disciplinary cognitive behavioral program might have beneficial effects on people with chronic neuropathic SCI pain.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes not covered for indications listed in the CPB:
96118 - 96120
Other CPT codes related to the CPB:
64550 - 64595
90791 - 90792
90832 - 90840
97010 - 97546
ICD-9 codes covered if selection criteria are met :
338.21 - 338.29
Chronic pain syndrome
Other ICD-9 codes related to the CPB:
290.0 - 319
337.20 - 337.29
Reflex sympathetic dystrophy
Neoplasm related pain (acute) (chronic)
346.00 - 346.93
Causalgia of upper limb
Causalgia of lower limb
401.0 - 405.99
Congestive heart failure, unspecified
710.0 - 733.99
Arthropathies and related disorders, dorsopathies, rheumatism, osteopathies, and chondropathies
800.00 - 999.9
Injury and poisoning
905.0 - 908.9
Late effects of injuries
V15.51 - V15.59
Personal history of injury
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.