LCD/NCD Portal

NCD10.3

 

INPATIENT HOSPITAL PAIN REHABILITATION PROGRAMS

 

Effective Date of this Version

• This is a longstanding national coverage determination. The effective date of this version has not been posted.

 

Benefit Category

• Inpatient Hospital Services

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Item/Service Description

• Pain rehabilitation programs are an innovative approach to the treatment of intractable pain.

o The goal of such programs is to give a patient the tools to manage and control his/her pain and thereby improve his/her ability to function independently.

• A hospital level pain rehabilitation program is one that employs a coordinated multidisciplinary team to deliver, in a controlled environment, a concentrated program that is designed to modify pain behavior through the treatment of the physiological, psychological, and social aspects of pain.

• Such programs generally include diagnostic testing, skilled nursing, psychotherapy, structured progressive withdrawal from pain medications, physical therapy and occupational therapy to restore physical fitness (mobility and endurance) to a maximal level within the constraints of a patient's physical disability, and the use of mechanical devices and/or activities to relieve pain or modify a patient's reaction to it:

o Nerve stimulator.

o Hydrotherapy.

o Massage.

o Ice.

o Systemic muscle relaxation training.

o Diversional activities.

• The nurse's responsibility in such pain rehabilitation programs is to observe and assess, on a continuing basis, a patient's condition and response to the program as reflected by his actions while in the nursing unit, and to assure that the atmosphere within the unit is not supportive of pain behavior.

• The day-to-day activities involved in carrying out the program are under the general supervision and, as needed, direct supervision of a physician.

 

Indications and Limitations of Coverage

• Since pain rehabilitation programs of a lesser scope than that described above would raise a question as to whether the program could be provided in a less intensive setting than on an inpatient hospital basis, carefully evaluate such programs to determine whether the program does, in fact, necessitate a hospital level of care.

o Some pain rehabilitation programs may utilize services and devices which are excluded from coverage, e.g., acupuncture dorsal column stimulator, and family counseling services. In determining whether the scope of a pain program does necessitate inpatient hospital care, evaluate only those services and devices which are covered.

o Although diagnostic tests may be an appropriate part of pain rehabilitation programs, such tests would be covered in an individual case only where they can be reasonably related to a patient's illness, complaint, symptom, or injury and where they do not represent an unnecessary duplication of tests previously performed.

• An inpatient program of 4 weeks' duration is generally required to modify pain behavior.

o After this period it would be expected that any additional rehabilitation services which might be required could be effectively provided on an outpatient basis under an outpatient pain rehabilitation program (see §10.4 of the NCD Manual) or other outpatient program.

o The first 7-l0 days of such an inpatient program constitute, in effect, an evaluation period.

o If a patient is unable to adjust to the program within this period, it is generally concluded that it is unlikely that the program will be effective and the patient is discharged from the program.

o On occasions a program longer than 4 weeks may be required in a particular case.

o In such a case there should be documentation to substantiate that inpatient care beyond a 4-week period was reasonable and necessary.

o Similarly, where it appears that a patient participating in a program is being granted frequent outside passes, a question would exist as to whether an inpatient program is reasonable and necessary for the treatment of the patient's condition.

• An inpatient hospital stay for the purpose of participating in a pain rehabilitation program would be covered as reasonable and necessary to the treatment of a patient's condition where the pain is attributable to a physical cause, the usual methods of treatment have not been successful in alleviating it, and a significant loss of ability to function independently has resulted from the pain.

o Chronic pain patients often have psychological problems which accompany or stem from the physical pain and it is appropriate to include psychological treatment in the multidisciplinary approach.

o However, patients whose pain symptoms result from a mental condition, rather than from any physical cause, generally cannot be successfully treated in a pain rehabilitation program.

 

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