Subject:
Principles of Pain Management
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) Medical Policies govern provision of care under the insurance benefit in an absolute fashion. Unlike medical policy, this concept policy is intended to aid in the evaluation of services provided to Horizon BCBSNJ subscribers and help determine when services are in concert with current accepted medical practice.
While there is great variation in the practice of pain management, current scientific literature in pain management suggests that there is a range of accepted practice. An effective strategy for pain management is predicated on several principles of pain management and this concept policy offers a framework for evaluating the medical necessity of interventional pain management procedures based on these principles.
This concept policy applies only if there is not a separate medical policy that outlines specific criteria for a particular interventional pain management procedure. If a separate medical policy does exist, then the criteria for medical necessity in that policy supersede the guidelines in this policy.
Policy:
(NOTE: :For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. Patient evaluation and management:
A. It is expected that prior to initiating therapy, there will be a comprehensive evaluation of the member presenting with pain with a detailed history, physical examination and diagnostic studies where appropriate, and an assessment that ultimately supports an impression or a diagnosis and a chosen treatment strategy.
- Appropriate diagnostic studies are to be used as an adjunct to the history and physical examination and the choice of the study should be guided by the history and physical examination and not used as a substitute for these necessary functions.
- Following the history, physical examination (PE) and necessary diagnostic testing, a treatment plan / options and pre-specified goals appropriate to the patient and diagnosis should be provided to the patient and documented in the medical records.
- The combined findings from the patient history, PE, and diagnostic evaluation should provide the foundation for an individualized treatment plan focused on the optimization of the risk-benefit ratio with an appropriate progression of treatment from a lesser to greater degree of invasiveness.
- Where a patient with chronic pain has taken opiates continuously for 3 months or longer, there should be evidence of co-management of behavioral health and medical conditions and plan to address potential opiate abuse or misuse.
- The rationale for a course of treatment will be well documented in the patient’s medical records.
B. Before the initial treatment procedure, patient should have been prescribed, tried and failed a trial of conservative (non-surgical or non-invasive) therapy (e.g., use of pharmacologic agents/analgesics for a reasonable period of time to induce a therapeutic response, physical therapy regimen, structured home exercise program).
C. On-going interval re-assessment is expected to be undertaken and documented before each repeat procedure to determine the effectiveness of treatment and support the need for further treatment.
D. For repeat procedures for chronic pain where a member has taken opiates continuously for 3 months or longer, there should be evidence of co-management of behavioral health and medical conditions and plan to address potential opiate abuse or misuse.
E Ongoing use of physical modalities (e.g., home exercises, physical therapy) by the patient is expected during the pain treatment period.
F. Duration of effect of pharmacologic agent should be taken into consideration in selecting the agent to be used.
G. If a given treatment or modality is not producing functional results within a reasonable time frame, the treatment should be either modified or abandoned. Reconsideration of a diagnosis should also occur in the event of a poor response to a seemingly rational intervention.
II. Documentation requirements:
A. Detailed history and physical examination prior to the initial treatment procedure.
B. Interval re-assessment of patient prior to each repeat treatment procedure.
- The initial response to a treatment procedure must be monitored carefully and documented in the patient’s medical records before a repeat procedure is performed.
- On-going re-assessment should be undertaken and documented in the progress notes showing significant response to the previous treatment to support the need for repeat procedures.
C. Use of standardized and validated self-report instruments (e.g. Visual Analog Scale or Numeric Pain Rating Scale, Wong-Baker FACES Pain Rating Scare) for subjective reports of pain and function.
D. Copy of imaging report (s) for medically necessary diagnostic studies that would support the impression/diagnosis and treatment plan.
Medicare Coverage:
Medicare Advantage Products are included in Horizon BCBSNJ Medical Policy: Principles of Pain Management (Introduction 010).
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Principles of Pain Management
References:
1. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010 Apr;112(4):810-33.
2. Chou R, Qaseem A, Snow V et al.; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct;147(7):478-91. Available at http://annals.org/article.aspx?articleid=736814
3. Health Care Association of New Jersey (HCAN). Pain management guideline. Hamilton (NJ): Health Care Association of New Jersey (HCANJ); 2006 Jul 18. (reaffirmed for currency by the developer in 2011). Available at http://www.guideline.gov/content.aspx?id=9744
3. Malanga GA, Nadler SF. Nonoperative treatment of low back pain. Mayo Clin Proc. 1999 Nov;74(11):1135-48. Available at http://www.mayoclinicproceedings.org/article/S0025-6196(11)65103-3/pdf
4. Boswell MV, Trescot AM, Datta S et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan;10(1):7-111.
5. Hooten WM, Timming R, Belgrade M et al. Institute for Clinical Systems Improvement. Assessment and Management of Chronic Pain. Updated November 2013. Available at https://www.icsi.org/_asset/bw798b/ChronicPain.pdf
6. Goertz M, Thorson D, Bonsell J et al. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 12. Available at https://www.icsi.org/_asset/bjvqrj/LBP.pdf
7. Manchikanti L, Boswell MV, Singh V et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009 Jul-Aug;12(4):699-802.
8. Manchikanti L, Falco FJ, Singh V et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part I: introduction and general considerations. Pain Physician. 2013 Apr;16(2 Suppl):S1-48. Review.
9. Manchikanti L, Abdi S, Atluri S et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013 Apr;16(2 Suppl):S49-283.
10. North American Spine Society. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. Clinical Guidelines for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy. 2012.
11. North American Spine Society. Coverage Policy Recommendations: Lumbar Epidural Injections. 12/04/2014.
12. UpToDate. Overview of the treatment of chronic pain. Literature review current through: March 2016
13. UpToDate. Evaluation of chronic pain in adults. Literature review current through: March 2016
14. UpToDate. Evaluation of the patients with neck pain and cervical spine disorders. Literature review current through: March 2016
15. UpToDate. Evaluation of low back pain in adults. Literature review current through: March 2016.
16. UpToDate. Subacute and chronic low back pain: Nonsurgical interventional treatment. Literature review current through: March 2016.
17. Rosenquist EWK. Overview of treatment of chronic pain. In: UpToDate, Aronson MD, Crowley M (Eds). UpToDate, Waltham, MA. (Accessed April 9, 2017.)
18. Rosenquist EWK. Evaluation of chronic pain in adults. In: UpToDate, Aronson MD, Crowley M (Eds). UpToDate, Waltham, MA. (Accessed on April 9, 2017.)
19. Isaac Z. Evaluation of the patients with neck pain and cervical spine disorders. In: UpToDate, Atlas SJ, Libman H, Lee SI (Eds), UpToDate, Waltham, MA. (Accessed April 9,2017.)
20. Wheeler SG, Wipf JE, Staiger TO, Deyo RA, Jarvik JG, Evaluation of low back pain in adults. In: UpToDate, Atlas SJ, Libman H, Lee SI (Eds), UpToDate, Waltham, MA. (Accessed on April 9, 2017.)
21. Chou R. Subacute and chronic low back pain: Nonsurgical interventional treatment. In: UpToDate, Atlas SJ, Crowley M (Eds), UpToDate, Waltham, MA. (Accessed on April 9, 2017.)
22. Rosenquist EWK. Overview of treatment of chronic pain. In: UpToDate, Aronson MD, Crowley M (Eds). UpToDate, Waltham, MA. (Accessed on January 8, 2019.)
23. Rosenquist EWK. Evaluation of chronic pain in adults. In: UpToDate, Aronson MD, Crowley M (Eds). UpToDate, Waltham, MA. (Accessed on January 8, 2019.)
24. Isaac Z. Evaluation of the patients with neck pain and cervical spine disorders. In: UpToDate, Atlas SJ, Libman H, Lee SI (Eds), UpToDate, Waltham, MA. (Accessed on January 8, 2019.)
25. Wheeler SG, Wipf JE, Staiger TO, Deyo RA, Jarvik JG, Evaluation of low back pain in adults. In: UpToDate, Atlas SJ, Libman H, Lee SI (Eds), UpToDate, Waltham, MA. (Accessed on January 8, 2019.)
26. Chou R. Subacute and chronic low back pain: Nonsurgical interventional treatment. In: UpToDate, Atlas SJ, Crowley M (Eds), UpToDate, Waltham, MA. (Accessed on January 8, 2019.)
27. Rosenquist EWK. Overview of the treatment of chronic non-cancer pain. In: UpToDate, Aronson MD, Crowley M (Eds). UpToDate, Waltham, MA. (Accessed on January 14, 2020.)
28. Rosenquist EWK. Evaluation of chronic pain in adults. In: UpToDate, Aronson MD, Crowley M (Eds). UpToDate, Waltham, MA. (Accessed on January 14, 2020.)
29. Isaac Z, Kelly HR. Evaluation of the patients with neck pain. In: UpToDate, Atlas SJ, Kunins L. (Eds), UpToDate, Waltham, MA. (Accessed on January 14, 2020.)
30. Wheeler SG, Wipf JE, Staiger TO, Deyo RA, Jarvik JG, Evaluation of low back pain in adults. In: UpToDate, Atlas SJ, Kunins L. (Eds), UpToDate, Waltham, MA. (Accessed on January 14, 2020.)
31. Chou R. Subacute and chronic low back pain: Nonsurgical interventional treatment. In: UpToDate, Atlas SJ, Kunins L. (Eds), UpToDate, Waltham, MA. (Accessed on January 14, 2020.)
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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