Policy/Criteria
Prior Approval is required.
Benefits for an Outpatient chronic pain program are limited to those programs that have achieved accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF).
Before benefits will be allowed for an outpatient chronic pain program the following guidelines must be met:
- Must have an identified diagnosis causing chronic non-malignant (non-cancer related pain) pain of at least six (6) months duration
- Must have documented history indicating prior treatment and have exhausted all usual and customary diagnostic procedures and treatment, including any recommended surgical treatment, without satisfactory improvement of pain.
- Incapacitation is such there is a severe lifestyle disruption because of chronic pain.
- Must be medically capable to perform daily physical activities.
- Member's mental health must be screened by the treating provider and any relevant psychiatric conditions which can interfere with treatment should be treated or have been stabilized
- Current substance use disorder risk must be evaluated by the treating provider and, if identified, coordination must be documented regarding treatment planning and/or coordination of care with the substance use disorder provider(s).
- Must not be admitted primarily for biofeedback.
Benefits will not be allowed to an outpatient pain program if the individual:
- Is being admitted to the outpatient pain program primarily for treatment of postural orthostatic tachycardia syndrome (POTS).
- Is unable to understand and carry out instructions.
- Exhibits aggressive or violent behavior.
- Has unrealistic expectations of what can be accomplished from the program.
- Is medically unstable.
Benefits for an Inpatient chronic pain programs would be medically appropriate and necessary when:
- Outpatient treatment is not feasible or has not been successful.
- Individual has major functional disabilities.
- Pain has caused extensive disruption in family functioning.
Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.
