Medicaid, commercial, and Medicare Advantage consistently cover physical, occupational, and chiropractic therapy for chronic noncancer low back pain, but they do not cover other options, including acupuncture or psychological therapies for low back pain, according to a study published in JAMA Network Open.1
Investigators performed a cross-sectional analysis across 16 states of commercial, Medicaid, and Medicare Advantage (n=15 for each) health plans during the year 2017. The main measurement of interest was the coverage status and medical necessity of back pain treatments examined. The use of tools such as prior authorization and cost-sharing was also examined.
The majority of payers were found to cover physical therapy (98%), chiropractic care (89%), and occupational therapy (96%). Medicaid was the only plan commonly covering transcutaneous electrical nerve stimulation (67%) and steroid injections (60%). Of all plans, 67% were found not to cover acupuncture, despite evidence indicating benefits associated with its use for the management of low back pain. Up to 80% of Medicaid plans lacked information regarding coverage of psychological interventions.
Although utilization management tools were found to be used frequently, criteria varied across plans regarding conditions for coverage, duration of treatment, and number of services covered under the plan. A total of 43 senior medical and pharmacy health plan executives from Medicaid managed care organizations (n=6), Medicare Advantage or Part D plans (n=2), commercial plans (n=9), and trade organizations (n=3) were interviewed in an effort to gather additional information on coverage policies for nonpharmacologic approaches to the management of acute and chronic low back pain.
These interviews indicated a “low level of integration between coverage decision making for nonpharmacologic and pharmacologic therapies, such as through the use of step therapy requirements that encourage use of physical therapy before initiation of long-acting or extended-release opioids.” Cost concerns, lack of inadequate evidence, and the possibility of inappropriate therapy use were indicated by interviewees as barriers to the expansion of nonpharmacologic treatment coverage.
Study limitations include potential for a lack of generalizability of the findings across all national healthcare plans.
“Well-conceived guidelines that encourage the use of evidence-based, nonpharmacological treatment options exist and must be enabled by changes in public health policies that better guide care delivery and reimbursement,” noted the authors of an accompanying editorial.2 “Health plans are uniquely positioned to bring about the sweeping changes needed to offer diverse pain management options for individuals with chronic pain. The findings from [this study] shed light on the ways in which current coverage policies run counter to this strategy and provide the beginnings of a roadmap to implement change on this critical issue.”
1. Heyward J, Jones CM, Compton WM, et al. Coverage of nonpharmacologic treatments for low back pain among US public and private insurers. JAMA Netw Open. 2018;1(6):e183044.
2. Goertz CM, George SZ. Insurer coverage of nonpharmacological treatments for low back pain—time for a change. JAMA Netw Open. 2018;1(6):e183037.