LCD/NCD Portal

NCD10.4

 

OUTPATIENT 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

• Outpatient Hospital Services Incident to a Physician's Service

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

 

Item/Service Description

• Some hospitals also provide pain rehabilitation programs for outpatients.

• In such programs, services frequently are provided in group settings even though they are being furnished pursuant to each patient's individualized plan of treatment.

 

Indications and Limitations of Coverage

• Coverage of services furnished under outpatient hospital pain rehabilitation programs, including services furnished in group settings under individualized plans of treatment, is available if the patient's 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 by the patient to function independently has resulted from the pain.

• If a patient meets these conditions and the program provides services of the types discussed in §10.3 of the NCD Manual, the services provided under the program may be covered.

• Noncovered services (e.g., vocational counseling, meals for outpatients, or acupuncture) continue to be excluded from coverage, and intermediaries would not be precluded from finding, in the case of particular patients, that the pain rehabilitation program is not reasonable and necessary under §1862(a)(1) of the Act for the treatment of their conditions. Transmittal Information

 

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