Description:
Pain is a localized sensation of discomfort, distress, or agony, resulting from the stimulation of specialized nerve endings. It serves as a protective mechanism insofar as it induces the sufferer to remove or withdraw from the source. The treatment of pain, regardless of the source, is a complex medical issue. For the purpose of this policy, chronic pain management, inpatient and outpatient pain management and pain management services will be addressed.

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.

An interdisciplinary chronic pain management program is one that includes physicians of different specialties as well as non­-physician providers. These providers specialize in the assessment and management of patients with a range of painful diagnoses and chronic pain the purpose of which is intended to provide the interventions needed to allow patients to develop pain coping skills and freedom from analgesic and opioid medication dependence. An interdisciplinary chronic pain management program must, at a minimum, include the following components for a patient's eligibility and participation:

• Customization of treatments tailored to the individual patient's needs;
• Specific measurable goals, patient and provider expectations for goal achievement, and end points of treatment;
• Monitor progress toward goal achievement;
• Active participation by the patient, caregivers, and significant others;
• Provide ongoing feedback to the patient, caregivers, and significant others about progress, performance, referral sources, primary care providers and the Health Plan;
• Maintenance strategies prepared in advance, documented and communicated to all appropriate individuals;
• Follow-up planned and scheduled as part of the maintenance interventions

Policy:
Pain Rehabilitation for Pain Management:
Treatment of a patient with chronic, severe, intractable pain presents numerous problems. The patient must be treated in a holistic manner incorporating not only the pain issues but also the medical management of a patient. Centers that treat patients for pain management have interdisciplinary staffs that have developed mechanisms necessary to allow patients to learn pain coping skills, including freedom from analgesic dependence. All inpatient and outpatient treatment admissions for pain management must have prior approval and meet the following criteria:

• 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 six 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).

The following would be considered contraindications to pain rehabilitation programs for chronic pain management:

• Member exhibits aggressive and/or violent behavior; or
• Member exhibits imminently suicidal tendencies; or
• Member has previously failed an adequate  interdisciplinary chronic pain management program; or
• Member has unrealistic expectations of what can be accomplished from the program (i.e., member expects and immediate cure); or
• Member is medically unstable (e.g., due to uncontrollable high blood pressure, unstable congestive heart failure or other poorly managed chronic medical conditions); or
• Member is unable to understand and carry out instructions.

Modality-oriented pain clinics and single disciplinary pain clinics are considered not appropriate for comprehensive treatment of members with chronic pain as they would not meet the definition of interdisciplinary that includes multiple physician and non-physician providers with multiple hours of intervention daily.

Rationale 
Chronic pain patients often have psychological problems that accompany or stem from physical pain. Hence, it is appropriate to include psychological treatment in the interdisciplinary 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.

Although many interdisciplinary 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 interdisciplinary pain treatment clinics/centers are effective for the management of appropriately selected patients with chronic nonmalignant 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 interdisciplinary pain programs for chronic non-cancer pain, prepared for the Agency for Healthcare Research and Quality (Jeffery, et al. 2011) found that interdisciplinary 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 interdisciplinary pain program treatment. Declining access to interdisciplinary 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 interdisciplinary 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 four 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-month follow-ups. 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 interdisciplinary cognitive behavioral program might have beneficial effects on people with chronic neuropathic SCI pain.

References  

1. Melzack R. Pain--an overview . Acta Anaesthesiol Scand. 1999;43(9):880-884.
2. Gallagher RM. Primary care and pain medicine. A community solution to the public health problem of chronic pain. Med Clin North Am. 1999;83(3):555-583,v.
3. Brady A, Cleeland C, Goldstein G, et al. Pain management guidelines: Implications for managed care--a roundtable discussion. Med Interface. 1997;Suppl:10-32.
4. Crook J, Tunks E. Pain clinics. Rheum Dis Clin North Am. 1996;22(3):599-611.
5. Bennett RM. Multidisciplinary group programs to treat fibromyalg ia patients Rheum Dis Clin North Am . 1996;22(2):351-367.
6. Hazard RG. Chronic low back pain and disability: The efficacy of functional restoration. Bull Hosp Jt Dis. 1996;55(4):2 13- 216.
7. Vines SW, Cox A, Nicoll L, et al. Effects of a multimodal pain rehabilitation program: A pilot study. Rehabil Nurs. 1996;2 1 (1):25-30,40.
8. Reinking J, Tempkin A,Tempkin T. Rehabilitation management of chronic pain syndromes. Nurse Pract Forum. 1995;6 (3):139-144.
9. Burns JW, Sherman ML, Devine J, et al. Association between workers' compensation and outcome following multidisciplinary treatment for chronic pain: Roles of mediators and moderators. Clin J Pain. 1995;11(2):94-102.
10. Talo S, Puukka P, Rytokoski U, et al. Can treatment outcome of chronic low back pain be predicted? Psychological disease consequences clarifying the issue. Clin J Pain. 1994;10(2) :107-121.
11. Jensen MP,Turner JA, Romano JM. Correlates of improvement in multidisciplinary treatment of chronic pain. J Consult Clin Psycho!. 1994;62 (1):172-179.
12. Sullivan MJ, Reesor K, Mikail S, et al. The treatment of depression in chronic low back pain: Review and recommendations. Pain. 1992;50(1):5-13.
13. Flor H, Fydrich T,Turk DC. Efficacy of multidisciplinary pain treatment centers A meta-analytic review. Pain. 1992;49 (2):221-230.
14. Csordas TJ, Clark JA. Ends of the line: Diversity among chronic pain centers. Soc Sci Med. 1992;34(4):383-393.
15. Deardorff WW, Rubin HS, Scott DW. Comprehensive multi-disciplinary treatment of chronic pain: A follow-up study of treated and non-treated groups. Pain. 1991;45(1):35-43.
16. Rowlingson JC, Hamill RJ. Organization of a multidisciplinary pain center. Mount Sinai J Med. 1991;58(3):267-272.
17. Rosomoff RS. Inpatient and outpatient chronic pain programs can be successful in returning patients to gainful employment. Clin J Pain. 1990;6 (1):80-83.
18. Peters JL, Large RG. A randomized control trial evaluating in- and outpatient pain management programmes. Pain. 1990;41 (3):283-293.
19. International Association for the Study of Pain. Task Force on Guidelines for Desirable Characteristics for Pain Treatment Facilities,1990.
20.  Langelier RP, Gallagher RM. Outpatient treatment of chronic pain groups for couples. Clin J Pain. 1989;5(3):227-231.
21. Orzesiak RC. Strategies for multidisciplinary pain management. Compendium. 1989;10(8):444, 446-448 , 450.
22. Simon JM. A multidisciplinary approach to chronic pain. Rehabil Nurs. 1989;14 (1):23-28.
23. Aronoff GM, McAlary PW, Witkower A, et al. Pain treatment programs: Do they return workers to the workplace? Occup Med. 1988;3(1):123-136.
24. Snow BR, Gusmorino P, Pinter I, et al. Multidisciplinary treatment of physicaland psychosocial disabilities in chronic pain patients: A follow-up report. Bull Hosp Jt Dis Orthop Inst. 1988;48(1):52-61.
25. Roy R. Pain clinics: Reassessment of objectives and outcomes. Arch Phys Med Rehabil. 1984;65(8):448-151.
26. Aronoff GM, Feldman JB, Campion TS. Management of chronic pain and control of long-term disability. Occup Med. 2000;15(4):755-770 , iv.
27. Gardea MA, Gatchel RJ. Interdisciplinary treatment of chronic pain. Curr Rev Pain. 2000;4(1):18-23.
28. Nicholson K. At the crossroads: Pain in the 21st century. NeuroRehabilitation . 2000;14(2):57-67.
29. .   Peat GM, Moores L, Goldingay S, et al. Pain management program follow-ups. A national survey of current practice in the United Kingdom. J Pain Symptom Manage. 2001;21(3):218-226.
30. Hadjistavropoulos HD, Clark J. Using outcome evaluations to assess interdisciplinary acute and chronic pain programs. Jt Comm J Qual lmprov. 2001;27(7):335-348 .
31. Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin J Pain.2002; 18 (6):355-365 .
32. Hornik J. Reflex sympathetic dystrophy . Edmonton, AB: Alberta Heritage Foundation for Medical Research (AHFMR); 1998.
33. Agency for Healthcare Research and Quality (AHRQ). Management of chronic central neuropathic pain following traumatic spinal cord injury. Evidence Report/Technology Assessment 45. Rockville, MD: AHRQ; 2001.
34. Ospina M, Harstall C. Multidisciplinary pain programs for chronic pain: Evidence from systematic reviews. HTA 30. Edmonton,AB: Alberta Heritage Foundation for Medical Research (AHFMR); 2003.
35. Management of Medically Unexplained Symptoms: Chronic Pain and Fatigue Working Group. VHA/DoD clinical practice guideline for the management of medically unexplained symptoms: chronic pain and fatigue. Washington , DC:Veterans Health Administration  (VHA), Department of Defense (DoD); July 2001.
36. Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary bio-psycho-social rehabilitation for chronic low back pain. Cochrane Database Syst Rev. 2006; (2):CD00963.
37. Karjalainen KA, Hurri H, Jauhiainen M, et al. Multidisciplinary rehabilitation for fibromyalgia and musculoskeletal pain in working age adults. Cochrane Database Syst Rev.1999;(3):CD001984.
38. Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain among working age adults. Cochrane Database Syst Rev.2003;(2):CD002193.
39. Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. Cochrane Database Syst Rev. 2003;(2):CD002194 .
40. French S. Multidisciplinary care for chronic low back pain. Evidence Centre Clinical Appraisal. Clayton, VIC: Centre for Clinical Effectiveness (CCE); October 2003.
41. Storro S, Moen J, Svebak S. Effects on sick-leave of a multidisciplinary rehabilitation programme for chronic low back, neck or shoulder pain: Comparison with usual treatment. J Rehabil Med. 2004;36(1):12-16. 
42. Patrick LE, Altmaier EM, Found EM. Long-term outcomes in multidisciplinary treatment of chronic low back pain: Results of a 13-year follow-up . Spine. 2004;29(8):850-855 .
43. Dysvik E, Natvig GK, Eikeland OJ, Brattberg G. Results of a multi-disciplinary pain management program: A 6- and 12- month follow-up study. Rehabii Nurs. 2005 ;30(5): 198-206.
44. Friedrich M, Gittler G, Arendasy M, Friedrich KM. Long-term effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain. Spine. 2005;30(9):995-1000.
45. Stones W, Cheong YC, Howard FM. Interventions for treating chronic pelvic pain in women. Cochrane Database Syst Rev. 2005;(2):CD000387 .
46. Stanos S, Houle TI. Multidisciplinary and interdisciplinary management of chronic pain. Phys Med Rehabil Clin N Am. 2006;17(2):435-450,  vii.
47. Dobkin PL, Boothroyd LJ. Management of chronic pain: Organization of health services. AETMIS 06-04. Montreal, QC: Agence d'Evaluation des Technologies et des Modes d'lntervention en Sante (AETMIS); 2006.
48. Swedish Council on Technology Assessment in Health Care (SBU). Methods of treating chronic pain -- a systematic review. SBU Report No. 177/1+2. Stockholm, Sweden; SBU; 2006.
49. Danish Centre for Evaluation and Health Technology Assessment (DACEHTA) . Pain school -- a health technology assessment  [summary]. Hague, the Netherlands; DACEHTA; 2006.
50. Townsend CO, Kerkvliet JL, Bruce BK, et al. A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal : Comparison of treatment outcomes based on opioid use status at admission. Pain. 2008;140(1):177-189.
51. Gunreben-Stempfle  B, Griessinger N, Lang E, et al. Effectiveness of an intensive multidisciplinary headache treatment program. Headache. 2009;49 (7):990-1000.
52. Gagnon S, Lensel-Corbeil G, Duquesnoy B, et al. Multicenter multidisciplinary training program for chronic low back pain: French experience of the Renodos back pain network (Reseau Nord Pas-de-Calais du DOS). Ann Phys Rehabil Med. 2009;52(1) :3-16.
53. Suman AL, Biagi B, Biasi G, et al. One-year efficacy of a 3-week intensive multidisciplinary non-pharmacological treatment program for fibromyalgia  patients. Clin Exp Rheumatol. 2009;27(1 ):7-14.
54. Norlund A, Ropponen A,Alexanderson K. Multidisciplinary interventions: Review of studies of return to work after rehabilitation for low back pain. J Rehab Med. 2009;41(3):115-121.
55. Ravenek MJ, Hughes ID, lvanovich N, et al. A systematic review of multidisciplinary outcomes in the management of chronic low back pain. Work. 2010;35(3):349-367.
56. Jeffery MM, Butler M, Stark A, Kane RL. Multidisciplinary Pain Programs for Chronic Noncancer Pain. Technical Brief No. 8. Prepared by Minnesota Evidence-based Practice Center under Contract No. 290-07-10064-1. AHRQ Publication No. 11- EHC064-EF. Rockville, MD:Agency for Healthcare Research and Quality; September 2011.
57. Heutink M, Post MW, Bongers-Janssen HM, et al. The CONECSI trial: Results of a randomized controlled trial of a multidisciplinary cognitive behavioral program for coping with chronic neuropathic pain after spinal cord injury . Pain. 2012;153(1):120-128.
58. Pieh C, Altmeppen J, Neumeier S, et al. Gender differences in outcomes of a multimodal pain management program. Pain. 2012;153(1):197-202.
59. Logan DE, Conroy C, Sieberg CB, Simons LE. Changes in willingness to selfmanage pain among children and adolescents and their parents enrolled in an intensive interdisciplinary pediatric pain treatment program. Pain. 2012;153 (9):1863-1870.
60. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev. 2014;9:CD000963 .
61. Fedoroff IC, Blackwell E, Speed B. Evaluation of group and individual change in a multidisciplinary pain management program. Clin J Pain. 2014;30(5):399- 408.
62. Cormier S, Lavigne GL, Choiniere M, Rainville P. Expectations predict chronic pain treatment outcomes. Pain. 2016;157 (2):329-338.

**Please refer to the specific plan of benefits for verbiage relating to exclusions, limitations or clarification of benefits**

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2014 Forward