Aetna Chronic Pain Programs coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Outpatient Chronic Pain Rehabilitation Program is medically necessary when member meets ALL of the following: (1) a surgical procedure or acute medical treatment was performed prior to program entry; AND (2) chronic pain duration exceeds 3 months; AND (3) pain cause is unknown OR attributable to a physical cause (not purely psychogenic); AND (4) member completed a pre-program psychological/behavioral health evaluation assessing comorbidities (PTSD, depression, anxiety, substance use disorder), and if such comorbidities are identified, member is receiving treatment for them AND continues to experience refractory/intractable pain; AND (5) documented failure, intolerance, or inadequate response to standard single-modality treatments (pharmacologic, physical/occupational therapy); AND (6) pain causes persistent limitations in activities of daily living (ADLs) or impaired social/vocational functioning; AND (7) referral from a physician (MD/DO), or from an NP/PA within state scope of practice; AND (8) member is medically and psychologically stable and capable of outpatient participation without safety concerns; AND (9) the program includes: assessment/monitoring, a validated pain rating scale, a person-centered care plan, treatment management including medication management, behavioral health facilitation, pain/health literacy counseling, crisis care, provider coordination, and an initial face-to-face visit of minimum 30 minutes by a physician or qualified health professional.
• Inpatient Chronic Pain Rehabilitation Program is medically necessary (coverage up to 21 days) when member meets ALL of the following: (1) a surgical procedure or acute medical treatment was performed prior to entry; AND (2) refractory chronic pain unimproved after a minimum of 6 weeks OR after completion of an outpatient multidisciplinary program (whichever is shorter); AND (3) meets TWO OR MORE of the following: inability to perform ADLs independently, needs extensive psychological/behavioral therapy, pain syndrome with comorbidity requiring supervised medical management/24-hour nursing, OR requires temporary separation from a detrimental home environment; AND (4) referral from a physician (MD/DO), or from an NP/PA within state scope of practice; AND (5) the program includes the same components required for the outpatient multidisciplinary program.
• Screening examination is medically necessary for members being considered for admission to a chronic pain rehabilitation program.
• Note: Substance dependence evaluation and referral to an addiction specialist is recommended for members with moderate-to-severe substance use disorders before enrollment in a chronic pain rehabilitation program.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 64553·PA verdict·Rate
• 64555·PA verdict·Rate
• 64561·PA verdict·Rate
• 64575·PA verdict·Rate
• 64585·PA verdict·Rate
• 64590·PA verdict·Rate
• 90791·PA verdict·Rate
• 90792·PA verdict·Rate
• 90832·PA verdict·Rate
• 90834·PA verdict·Rate
• 90837·PA verdict·Rate
• 90853·PA verdict·Rate
• 97010·PA verdict·Rate
• 97110·PA verdict·Rate
• 97140·PA verdict·Rate

Documentation required

• Pre-program psychological and behavioral health evaluation (assessing comorbidities such as PTSD, depression, anxiety, and substance use disorder).
• Referral documentation from a qualified provider (physician MD/DO, or NP/PA within state scope of practice).
• Administration of a validated pain rating scale.
• Development of a person-centered care plan.
• Documentation of ongoing communication/coordination among treating providers.
• Documentation of failure, intolerance, or inadequate response to standard single-modality treatments (pharmacologic, physical/occupational therapy).

Frequently asked questions

When does Aetna cover Chronic Pain Programs (CPT 64553), and what gets it denied?

Aetna CPB 0237 covers outpatient and inpatient multidisciplinary chronic pain rehabilitation programs (inpatient up to 21 days) only when the member has refractory chronic pain (over 3 months) of physical/unknown cause, has failed standard single-modality treatments, has completed a pre-program psychological/behavioral evaluation, is referred by a qualified provider, and is medically and psychologically stable. Single-disciplinary/modality-oriented pain clinics, the Foundation PISM urine test panel, and NeuroFlow remote monitoring are not covered, and entry is contraindicated for members who are violent, imminently suicidal, medically unstable, have unrealistic expectations, cannot follow instructions, or have already failed an adequate multidisciplinary program. Coverage criteria include: Outpatient Chronic Pain Rehabilitation Program is medically necessary when member meets ALL of the following: (1) a surgical procedure or acute medical treatment was performed prior to program entry; AND (2) chronic pain duration exceeds 3 months; AND (3) pain cause is unknown OR attributable to a physical cause (not purely psychogenic); AND (4) member completed a pre-program psychological/behavioral health evaluation assessing comorbidities (PTSD, depression, anxiety, substance use disorder), and if such comorbidities are identified, member is receiving treatment for them AND continues to experience refractory/intractable pain; AND (5) documented failure, intolerance, or inadequate response to standard single-modality treatments (pharmacologic, physical/occupational therapy); AND (6) pain causes persistent limitations in activities of daily living (ADLs) or impaired social/vocational functioning; AND (7) referral from a physician (MD/DO), or from an NP/PA within state scope of practice; AND (8) member is medically and psychologically stable and capable of outpatient participation without safety concerns; AND (9) the program includes: assessment/monitoring, a validated pain rating scale, a person-centered care plan, treatment management including medication management, behavioral health facilitation, pain/health literacy counseling, crisis care, provider coordination, and an initial face-to-face visit of minimum 30 minutes by a physician or qualified health professional.; Inpatient Chronic Pain Rehabilitation Program is medically necessary (coverage up to 21 days) when member meets ALL of the following: (1) a surgical procedure or acute medical treatment was performed prior to entry; AND (2) refractory chronic pain unimproved after a minimum of 6 weeks OR after completion of an outpatient multidisciplinary program (whichever is shorter); AND (3) meets TWO OR MORE of the following: inability to perform ADLs independently, needs extensive psychological/behavioral therapy, pain syndrome with comorbidity requiring supervised medical management/24-hour nursing, OR requires temporary separation from a detrimental home environment; AND (4) referral from a physician (MD/DO), or from an NP/PA within state scope of practice; AND (5) the program includes the same components required for the outpatient multidisciplinary program.; Screening examination is medically necessary for members being considered for admission to a chronic pain rehabilitation program.; Note: Substance dependence evaluation and referral to an addiction specialist is recommended for members with moderate-to-severe substance use disorders before enrollment in a chronic pain rehabilitation program.. Applies to 15 codes: 64553, 64555, 64561, 64575, 64585, 64590, 90791, 90792, 90832, 90834, 90837, 90853, 97010, 97110, 97140. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Pre-program psychological and behavioral health evaluation (assessing comorbidities such as PTSD, depression, anxiety, and substance use disorder).; Referral documentation from a qualified provider (physician MD/DO, or NP/PA within state scope of practice).; Administration of a validated pain rating scale.; Development of a person-centered care plan.; Documentation of ongoing communication/coordination among treating providers.; Documentation of failure, intolerance, or inadequate response to standard single-modality treatments (pharmacologic, physical/occupational therapy). Policy exclusions and limitations: Experimental, investigational, or unproven (effectiveness not established): Foundation PISM (Ethos Laboratories) functional biomarker urine test panel for chronic pain management and for all other indications.; Experimental, investigational, or unproven (effectiveness not established): NeuroFlow (remote monitoring of physiologic parameters) for monitoring individuals in pain management and for all other indications.; Not medically necessary: Modality-oriented pain clinics and single disciplinary pain clinics are considered not medically necessary and inappropriate for comprehensive treatment of members with chronic pain.; Not medically necessary: Neuropsychological evaluation/testing for members with chronic pain being considered for treatment solely with narcotic pain medication.; Not medically necessary: Inpatient admission for the medical and psychological evaluations required before admission to an inpatient chronic pain treatment program — these evaluations should be performed on an outpatient basis.; Not medically necessary: Continued inpatient chronic pain treatment for members who are not participating (e.g., failure to attend scheduled treatment sessions) in the program.; Not medically necessary: An inpatient chronic pain management program for persons who have failed a prior adequate multidisciplinary (e.g., CARF-accredited) chronic pain management program.; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member exhibits aggressive and/or violent behavior.; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member exhibits imminently suicidal tendencies.; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member has previously failed an adequate multidisciplinary (e.g., Commission on Accreditation of Rehabilitation Facilities [CARF] accredited) chronic pain management program.; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member has unrealistic expectations of what can be accomplished from the program (i.e., expects an immediate cure).; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member is medically unstable (e.g., due to uncontrollable high blood pressure, unstable congestive heart failure, or other medical conditions).; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member is unable to understand and carry out instructions. Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for Chronic Pain Programs?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Pre-program psychological and behavioral health evaluation (assessing comorbidities such as PTSD, depression, anxiety, and substance use disorder).; Referral documentation from a qualified provider (physician MD/DO, or NP/PA within state scope of practice).; Administration of a validated pain rating scale.; Development of a person-centered care plan.; Documentation of ongoing communication/coordination among treating providers.; Documentation of failure, intolerance, or inadequate response to standard single-modality treatments (pharmacologic, physical/occupational therapy).

What does Aetna exclude for Chronic Pain Programs?

Policy exclusions and limitations: Experimental, investigational, or unproven (effectiveness not established): Foundation PISM (Ethos Laboratories) functional biomarker urine test panel for chronic pain management and for all other indications.; Experimental, investigational, or unproven (effectiveness not established): NeuroFlow (remote monitoring of physiologic parameters) for monitoring individuals in pain management and for all other indications.; Not medically necessary: Modality-oriented pain clinics and single disciplinary pain clinics are considered not medically necessary and inappropriate for comprehensive treatment of members with chronic pain.; Not medically necessary: Neuropsychological evaluation/testing for members with chronic pain being considered for treatment solely with narcotic pain medication.; Not medically necessary: Inpatient admission for the medical and psychological evaluations required before admission to an inpatient chronic pain treatment program — these evaluations should be performed on an outpatient basis.; Not medically necessary: Continued inpatient chronic pain treatment for members who are not participating (e.g., failure to attend scheduled treatment sessions) in the program.; Not medically necessary: An inpatient chronic pain management program for persons who have failed a prior adequate multidisciplinary (e.g., CARF-accredited) chronic pain management program.; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member exhibits aggressive and/or violent behavior.; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member exhibits imminently suicidal tendencies.; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member has previously failed an adequate multidisciplinary (e.g., Commission on Accreditation of Rehabilitation Facilities [CARF] accredited) chronic pain management program.; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member has unrealistic expectations of what can be accomplished from the program (i.e., expects an immediate cure).; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member is medically unstable (e.g., due to uncontrollable high blood pressure, unstable congestive heart failure, or other medical conditions).; Contraindication (not medically necessary) for entry into a chronic pain rehabilitation program: Member is unable to understand and carry out instructions. Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT