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Coverage criteria policies

Chronic Pain - Multidisciplinary Intensive Day Treatment Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

  • Requires prior authorization by the Behavioral Health Department
  • The HealthPartners’ prior authorization form is completed in full by the primary care physician or primary attending health care provider and submitted to the Behavioral Health department for review and authorization consideration.
  • If coverage is authorized, multidisciplinary intensive pain programs are generally covered under the member’s medical benefit as a rehabilitation program.
  • The following conditions are not eligible for coverage at the multidisciplinary pain programs within HealthPartners Designated Provider Network because there are other programs more appropriate for these conditions: Pain due to cancer, migraines, chemical dependency or in the context of palliative care or end-of-life management.

Coverage

Outpatient multidisciplinary pain programs are covered when they meet the criteria listed below and are delivered by a program in the designated network for chronic pain management. Chronic pain is often a persistent, life-altering condition. The goal of a treatment program is pain management, not elimination of pain.

The outpatient programs in the Designated Pain Management Program Network are:

  • Mayo Clinic Pain Rehabilitation Program
  • Courage Kenny Chronic Pain Rehabilitation Program
  • Essentia Health – Duluth Clinic Pain Management Program

Indications that are covered

Outpatient multidisciplinary pain programs for chronic pain are covered when all of the following are met (must meet 1-13):

  1. The member is 18 or older
  2. The member has been evaluated in the last 12 months by a physician who specializes in chronic pain
  3. The member has an identified diagnosis causing chronic pain syndrome
  4. The primary care physician (PCP) or primary attending health care provider has utilized the following ICSI interventions in the member’s plan of care – both a. & b. and at least two of c. – g.:
    1. Physical therapy modalities– member completed 10-12 consecutive visits in the last six(6) months
    2. The patient has participated in a course of 10-12 sessions of Cognitive-Behavioral Therapy in the last six(6) months with a licensed mental health professional with experience/training in Chronic Pain
    3. Passive Physical Treatments
      1. Massage
      2. TENS
      3. Spinal manipulation therapy
      4. Traction
      5. Ultrasound
      6. Lumbar spine corsets and braces
    4. Acupuncture
    5. Therapeutic procedures/injections
    6. Fitness/Exercise program
    7. Medications: antidepressants, anticonvulsants, topical agents
  5. The primary care physician or primary attending health care provider has documentation that recent and adequate (as defined by 10 consecutive sessions in past six(6) months with a single provider) trials of interventions under this care plan have failed.
  6. The primary care physician or primary attending health care provider supports participation in the multidisciplinary pain program as the next level of intervention;
  7. The primary care physician or primary attending health care provider agrees to collaborate with and to support the multidisciplinary treatment plan after the program completion as the patient returns to their care.
  8. The primary care physician and the patient understand that the goal of the pain program is not medication management or pain relief but development of new skills for the self-management of chronic pain.
  9. The patient has the cognitive and physical capacity to participate in the psychological and physical interventions provided by a pain program.
  10. Pain has affected the patient’s level of function for activities of daily living (ADLS).
  11. The patient is agreeable to the conditions of the treatment program including but not limited to:
    1. full participation in scheduled activities including physical exercise;
    2. family participation;
    3. abstaining from alcohol and non-prescribed drugs for the duration of the program;
    4. learning about pain and stress management techniques;
    5. striving for return to productive lifestyle including return to work and normal activities.
  12. The patient is willing to participate in HealthPartners Case Management as appropriate (behavioral health case management or medical case management as clinically appropriate).
  13. The patient and physician have agreed to detoxification if necessary and a multidisciplinary pain program has been determined to be the appropriate location for this to occur.

Indications that are not covered

  1. The following conditions are not eligible for coverage at the multidisciplinary pain programs within HealthPartners Designated Provider Network because there are other programs more appropriate for these conditions: Pain due to cancer, migraines, chemical dependency or in the context of palliative care or end-of-life management.
  2. The patient does not have the cognitive or physical capacity to participate in the psychological and physical interventions provided by a pain program including physical exercise.

Definitions

A multidisciplinary pain program is a comprehensive approach to the patient with chronic pain, which:

  • Is delivered in a single facility, is time limited, structured and group based;
  • Conducts a comprehensive assessment for physical and behavioral health; and
  • Integrates the interventions of physicians, behavioral health specialists, physical therapists and occupational health therapists;
  • Develops an individualized care plan.
  • The goal of treatment is an emphasis on improving function through the development of long-term, self-management skills including fitness and a healthy lifestyle.

HealthPartners utilizes the ICSI Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management Guideline to determine appropriate care. (Please see link at the bottom of this policy.)  These guidelines define chronic pain as pain that persists beyond the normal time expected for healing and is associated with the onset of pathophysiologic changes in the central nervous system that adversely affect the individual's emotional and physical well-being. The experience of chronic pain reflects a complex interplay of emotional, psychological and social factors that contribute to an individual's worsening ability to function.

A time longer than the anticipated healing time for their condition - patients should be thoroughly evaluated for the presence of chronic pain.

Chronic Pain Syndrome is at the end of the spectrum of chronic pain. It is defined as a constellation of behaviors related to persistent pain that represents significant life role disruption.

Chronic Pain Syndrome may require Multidisciplinary Pain Management, the criteria for which are the topic of this coverage policy. It is anticipated that lower, less intensive levels of care have been attempted, documented and precede higher, more intensive levels of care.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Hooten M, Thorson D, Bianco J, Bonte B, Clavel Jr A, Hora J, Johnson C, Kirksson E, Noonan MP, Reznikoff C, Schweim K, Wainio J, Walker N. Institute for Clinical Systems Improvement. Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management. Updated September 2016. LINK

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Policy activity

  • 07/01/2005 - Date of origin
  • 08/01/2017 - Effective date
Review date
  • 02/2017
Revision date
  • 07/11/2017

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