HIGHMARK COMMERCIAL MEDICAL POLICY - WEST VIRGINIA

 
 
Medical Policy:
Y-23-003
Topic:
Chronic Pain Management
Section:
Therapy
Effective Date:
September 17, 2018
Issued Date:
December 7, 2020
Last Revision Date:
November 2020
Annual Review:
November 2020
 
 

Chronic pain is defined as a non-malignant, non-end of life pain lasting more than three months or longer than the duration of normal tissue healing. 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. Chronic pain may be caused by physical, psychological, and environmental factors. Chronic non-malignant pain encompasses many painful disorders including but not limited to back pain, migraine headaches, diabetic neuropathy, dental and orofacial pain, and arthritic pain.

An event is defined as an adverse or damaging medical occurrence resulting in an acute exacerbation of an existing chronic pain condition.

Policy Position

West Virginia Mandate

West Virginia Senate Bill 273 seeks to promote the physical and mental health of West Virginia citizens by, in relevant part, attempting to reduce opioid addiction by prescribing alternative treatments to help individuals manage chronic pain.  Senate Bill 273, in relevant part, amends the Chapter 16 of the West Virginia Code, relating to Public Health to add §16-54-1 et seq. (Treatment of Pain) (the “Act”).  The Act is effective June 7, 2018 and applies to insurers who offer insurance policies in West Virginia, the Bureau for Medical Services, and the Public Employees Insurance Agency.

The requirements of the Act are as follows:

(a)    When patients seek treatment for any of the myriad conditions that cause pain, a health care practitioner shall refer or prescribe to a patient any of the following treatment alternatives, based on the practitioner’s clinical judgment and the availability of the treatment, before starting a patient on an opioid: physical therapy, occupational therapy, acupuncture, massage therapy, osteopathic manipulation, chronic pain management program, and chiropractic services, as defined in §30-16-3 of this code.

(b)   Nothing in this section should be construed to require that all of the treatment alternatives set forth in (a) are required to be exhausted prior to the patient receiving a prescription for an opioid.

(c)    At a minimum, an insurance provider who offers an insurance product in this state, the Bureau for Medical Services, and the Public Employees Insurance Agency shall provide coverage for 20 visits per event of physical therapy, occupational therapy, osteopathic manipulation, a chronic pain management program, and chiropractic services, when ordered by a health care practitioner to treat conditions that cause chronic pain.

(d)   A patient may seek treatment for physical therapy, occupational therapy, osteopathic manipulation, a chronic pain management program, and chiropractic services prior to seeking treatment from a practitioner and a practitioner referral is not required as a condition of coverage by the Bureau for Medical Services, the Public Employees Insurance Agency, and any insurance provider who offers an insurance product in this state. Any deductible, coinsurance, or co-pay required for any of these services may not be greater than the deductible, coinsurance, or co-pay required for a primary care visit.

(e)   Nothing in this section precludes a practitioner from simultaneously prescribing an opioid and prescribing or recommending any of the procedures set forth in (a).

For chronic pain management services ALL of the following applies:

  • The services must be provided in an outpatient setting and 
  • The patient must have a diagnosis of chronic pain and 
  • The patient must have an adverse or damaging medical occurrence resulting in an acute exacerbation of an existing chronic pain condition.

G0237

G0238

G0239

G0281

G0282

G0283

G0295

G0329

S8930

S8948

S8950

S8990

S9090

97010

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97139

97140

97150

97161

97162

97163

97164

97169

97170

97171

97172

97750

97799

98925

98926

98927

98928

98929

98940

98941

98942

98943

G0515

97127

97165

97166

97167

97168

97530

97533

97535

97537

97542

97755

97760

97761

97763

90785

90791

90792

90832

90833

90834

90836

90837

90838

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

 

 

 


G89.21

G89.28

G89.29

G89.4

 

 

 


Place of Service: Outpatient

Chronic Pain Management is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



Links





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.