Analysis of State Insurance Coverage for Nonpharmacologic Treatment of Low Back Pain as Recommended by the American College of Physicians Guidelines

Robert Bonakdar, MD,1 Dania Palanker, JD, MPP,2 and Megan M Sweeney, MPH1,3

Short abstract

Background

In 2017, the American College of Physicians (ACP) released guidelines
encouraging nonpharmacologic treatment of chronic low back pain (LBP). These
guidelines recommended utilization of treatments including multidisciplinary
rehabilitation, acupuncture, mindfulness-based stress reduction (MBSR), tai
chi, yoga, progressive relaxation, biofeedback, cognitive behavioral therapy
(CBT), and spinal manipulation.

Objective

We aimed to determine status of insurance coverage status for multiple
nonpharmacological pain therapies based on the 2017 Essential Health
Benefits (EHB) benchmark plans across all states.

Methods

The 2017 EHB benchmark plans represent the minimum benefits required in all
new policies in the individual and small group health insurance markets and
were reviewed for coverage of treatments for LBP recommended by the ACP
guidelines. Additionally, plans were reviewed for limitations and
exclusionary criteria.

Results

In nearly all state-based coverage policies, chronic pain management and
multidisciplinary rehabilitation were not addressed. Coverage was most
extensive (supported by 46 states) for spinal manipulation. Acupuncture,
massage, and biofeedback were each covered by fewer than 10 states, while
MBSR, tai chi, and yoga were not covered by any states. Behavioral health
treatment (CBT and biofeedback) coverage was often covered solely for mental
health diagnoses, although excluded for treating LBP.

Conclusion

Other than spinal manipulation, evidence-based, nonpharmacological therapies
recommended by the 2017 ACP guidelines were routinely excluded from EHB
benchmark plans. Insurance coverage discourages multidisciplinary
rehabilitation for chronic pain management by providing ambiguous
guidelines, restricting ongoing treatments, and excluding behavioral or
complementary therapy despite a cohesive evidence base. Better EHB plan
coverage of nondrug therapies may be a strategy to mitigate the opioid
crisis. Recommendations that reflect current research-based findings are
provided to update chronic pain policy statements.

Keywords: chronic pain, complementary and alternative medicine, health policy, integrative medicine, public health

Methods

The 2017 EHB benchmark plan coverage manuals and summary statements for each state
and the District of Columbia published by the Centers for Medicare & Medicaid
Services were electronically identified. Authors reviewed plan information for treatments recommended by the ACP
guidelines including acupuncture, biofeedback, CBT, yoga, MBSR, tai chi, progressive
relaxation, massage, and manipulation. We aimed to determine coverage for
multidisciplinary rehabilitation as a well as massage, tai chi, and yoga as distinct
entities beyond traditionally covered physical therapies.

Each EHB benchmarks for all 50 states and the District of Columbia were reviewed for
coverage determination. Nonpharmacological treatments were coded via binomial
classification according to coverage status. Unmentioned, unclear, or contradictory
treatments were coded as “not covered.” This classification is supported by policy
statements shown to exclude services not specifically mentioned by default. Additionally, plans were reviewed to determine whether:

  • Mental health treatments, including CBT, were exclusively covered for
    disorders classified in the Diagnostic and Statistical Manual of Mental
    Disorders, 5th Edition (DSM-5®) implying lack of coverage for pain conditions (DSM-5
    exclusions).

  • Complementary and alternative medicine (CAM) therapies were excluded
    based on plan designations (CAM exclusion). This incorporated exclusion
    based on wording such as complementary, alternative,
    holistic
    , or nontraditional.

  • Massage was covered as a distinct entity as opposed to a subcomponent of
    physical and manipulative therapy that may not be billed by certain
    providers (eg, massage therapists).

  • Chronic pain or pain management in the nonacute, nonpalliative setting
    was mentioned as a distinct entity.

  • Multidisciplinary rehabilitation was mentioned and whether it was
    described as a distinct multiprofession collaborative therapy.

  • Tai chi, yoga, and MBSR were designated “not covered.” In cases where
    individual or group exercise, fitness, recreation, or stress management
    therapies were not covered, exclusions were noted.

  • Other exclusions and limitations were listed for the above therapies
    including practitioner exclusions, visit limits, and requirements for
    combined therapies.

  • The process for coverage determinations was consistent within policy
    statements.

Results

Analysis of Nonpharmacological Treatments

Manipulation

Manipulation, chiropractic, or osteopathic coverage determination was noted
in plan information for all states. Coverage was recorded in a binary
fashion regardless of the type of professional providing the treatment.
Spinal manipulation was covered in 46 states and the District of Columbia.
Four states (California, Colorado, Hawaii, and Oregon) did not cover
manipulation. In several benchmarks, manipulation was only covered for acute
musculoskeletal disorders and not a benefit when provided for chronic
conditions. In most other benchmarks, there was not clear elaboration of
coverage for chronic conditions.

Acupuncture

Acupuncture coverage determination was noted in plan information for all
states. Five states (Arkansas, California, Maryland, New Mexico, and
Washington) consider acupuncture an EHB. In 1 additional state (Montana),
acupuncture was noted as a benefit in the summary statement, despite
contradiction in the official coverage manual under CAM exclusions. Based on the discrepancy, acupuncture was categorized as not covered,
therefore confirming coverage in 5 total states. See Table 1 for details.

Table 1.

Coverage and Limitations for Selected Nonpharmacological Therapies
Related 2017 Essential Health Benefits Benchmark Plans Across All
States (N = No; Y = Yes).

State Acupuncture Manipulation Limitationsa DSM Exclusionsb CAM Exclusionsc
Alabama N Y Y Y Y
Alaska Y Y Y Y Y
Arizona N Y Y Y N
Arkansas N Y Y Y N
California Y N N N
Colorado N N Y N
Connecticut N Y Y Y N
Delaware N Y Y N N
District of Columbia N Y Y Y N
Florida N Y Y Y Y
Georgia N Y Y Y Y
Hawaii N N N Y
Idaho N Y Y Y Y
Illinois N Y Y Y N
Indiana N Y Y Y Y
Iowa N Y N N N
Kansas N Y N N Y
Kentucky N Y Y Y Y
Louisiana N Y Y Y Y
Maine N Y Y Y Y
Maryland Y Y Y Y N
Massachusetts N Y N N N
Minnesota N Y N N N
Mississippi N Y Y Y N
Michigan N Y Y Y Y
Missouri N Y Y N Y
Montana Y Y Y N Y
Nebraska N Y Y Y N
Nevada N Y Y N N
New Hampshire N Y Y N Y
New Jersey N Y Y Y N
New Mexico Y Y Y Y Y
New York N Y N Y N
North Carolina N Y Y Y Y
North Dakota N Y Y N Y
Ohio N Y Y Y Y
Oklahoma N Y N Y N
Oregon N N N Y
Pennsylvania N Y Y Y Y
Rhode Island N Y Y N Y
South Carolina N Y N Y N
South Dakota N Y N Y N
Tennessee N Y Y N Y
Texas N Y Y Y N
Utah N Y N Y Y
Vermont N Y N N Y
Virginia N Y Y Y Y
Washington Y Y Y N N
West Virginia N Y Y N N
Wisconsin N Y N Y Y
Wyoming N Y Y Y Y

Abbreviations: CAM, complementary and alternative medicine; DSM,
Diagnostic and Statistical Manual of Mental Disorders; –, refers
to nonapplicability of limitations for states that do not cover
manipulation.

aLimitations related to manipulation services based on
treatment or cotreatment visit limits related to physical
therapy, occupational therapy, or acupuncture.

bBehavioral therapy coverage related to DSM definition
of mental health diagnoses (does not include pain).

cDenial of treatments based on labeling as a CAM
therapy despite supporting evidence.

Massage

Massage or massage therapy coverage determinations were identified in 37
states’ plans. Of these, 28 plans did not cover massage either explicitly
(13 states) or cited it within a CAM exclusion (15 states). Two states (West
Virginia and Maine) regarded massage a covered treatment but simultaneously
listed it as a CAM exclusion. Three states (Illinois, Texas, and Florida)
appeared to cover massage but either did not have specifics on coverage or
excluded certain types of massage. Four states only covered massage if
administered by physical therapists (California and New Mexico),
chiropractors (Louisiana), or both practitioners (Minnesota). Given the
restrictions on which health professionals were approved to administer
massage, the subsequent 4 states were not included in the cohesive coverage
count in states supporting massage therapy. Detailed plan information deemed
massage could not be billed as a separate entity or by other licensed
therapists such as massage therapists. Based on these subtle restrictions,
the levels of coverage for massage as a distinct entity performed by a
massage therapist are likely less than noted.

Biofeedback

Biofeedback coverage determination was evident in 30 states’ plans.
Biofeedback was specifically mentioned as a covered benefit for pain
management in 1 state (Arizona) plan. The remaining 29 state policies
explicitly deny biofeedback for various reasons, including unconditional
denial of biofeedback, denial based on biofeedback based on CAM designation,
or denial based on coverage of biofeedback for medical conditions that did
not include LBP. The most commonly cited, covered medical conditions were
incontinence, Raynaud’s disease, and headache disorders. Of note, 1 state
(Florida) plan excluded biofeedback in 1 section (as a CAM exclusion) but
cited it as a covered benefit in an additional area. Another (Michigan)
mentioned biofeedback as potentially covered based on medical necessity “as
determined according to our medical policies.” Based on the general level of
denial in other state plans, this was deemed as unclear and categorized as
not covered.

Cognitive behavioral therapy

Specific CBT coverage determinations were noted in 2 states’ plans with pain
coverage remaining unclear. In 1 state (Connecticut), CBT was noted as a
covered benefit, although the plan stated, “There is no coverage for other
conditions not defined as mental disorders in the most recent edition of the
American Psychiatric Association’s DSM-5®,” although CBT may be covered
under behavioral services when not specifically noted, the DSM-5® was noted
in 39 other plans and was frequently leveraged in denial of coverage for
behavioral services for conditions including chronic pain.

Multidisciplinary rehabilitation and chronic pain management

We attempted to determine the likelihood of multidisciplinary rehabilitation
and chronic pain management in EHB plans. Nearly, all plans failed to
specifically address chronic pain. In 1 state (Iowa) plan, there were only 3
mentions of “pain”—all of which pertained to treatment of acute or emergent
pain. When chronic pain was mentioned in 1 state (Alabama) plan, it was in
the context of denying treatment: “The following services and supplies are
not covered: … Treatment for chronic pain … .” Similarly, multidisciplinary rehabilitation defined as
“multidimensional rehabilitation” composed of a minimum of the physical
dimension and one of the other related dimensions (psychological, social, or
occupational) as a distinct entity beyond unimodal physical therapy was not
mentioned and could not be evaluated in several coverage statements. A potential exception in 1 plan (Florida) noted, “Pain Management
includes, but is not limited to, services for pain assessment, medication,
physical therapy, biofeedback, and/or counseling. Pain rehabilitation
programs are programs featuring multidisciplinary services directed toward
helping those with chronic pain to reduce or limit their pain.” This plan
also excluded nonpharmacological treatments (eg, biofeedback), thereby
contradicting coverage for multidisciplinary rehabilitation.

Specific exercise programs and stress management programs (yoga, tai chi,
MBSR)

State policies were analyzed for coverage of practitioner and
modality-specific exercise and stress management programs distinct from
traditional physical therapy. These programs were discussed minimally in
coverage statements. Yoga was mentioned in 5 state policies (Florida,
Georgia, Michigan, New York, and Rhode Island) and was noted as a noncovered
benefit due to exclusion of CAM therapies or exercise in all states. Tai chi
was only mentioned in 1 plan (Rhode Island) and deemed not covered. MBSR was
not included within any policy statements. Other types of stress management
programs (eg, meditation) were noted in 10 states—7 of which deemed
meditation not covered due to CAM exclusions. Three states provided some
type of stress management typically in an online or phone-based coaching.
Finally, a small number of states mentioned potential discounts at fitness
centers, although coverage specifics and availability of treatments was
unclear.

Nonspecific exclusions

Even if nonpharmacological therapies were originally noted as covered options
for patients diagnosed with LBP, plan information for all states
incorporated several exclusions and limitations that influenced ultimate
coverage status of important treatments noted in the ACP guidelines.
Specific exclusionary criteria are reviewed in Table 1.

While at least 7 states did not limit number of annual treatments, most
states capped number of visits for single modalities, which were as low as
10 treatments per year (eg, manipulation). A number of states placed
combination treatment limits (as low as 20) for 2 or more modalities. In 1
state (Washington), a total of 20 combined yearly treatments were available
for manipulation, physical, and occupational therapy.

Although most plan information did not specifically mention the process for
determining coverage, some states did elaborate on potential sources of
coverage. One example noted that claims were based, among other factors, on
review of sources including, “Generally accepted standards of medical,
behavioral health and dental practice based on credible scientific evidence
recognized in published peer reviewed medical or dental literature.”

CAM exclusions

In addition to the exclusion of behavioral treatments for pain as noted
above, a number of the ACP recommended treatments were also excluded due to
their designation in state plans as CAM therapies. At least 27 states had
wording which excluded treatments that were deemed
complementary, alternative,
holistic or nontraditional. No
standard listing of treatments was noted, although acupuncture, biofeedback,
massage, and biofeedback were often listed. In some cases (eg, biofeedback
in Florida), treatments were both listed as covered under the policy
statement as well as not covered under CAM exclusions. The rationale used
for denial of services was typically not explained.

Behavioral health for pain exclusions

While mental and behavioral treatments are listed as EHB, explicit coverage
for such therapies for pain management was rare. A number of states as noted
above had wording excluding behavioral health treatments provided for
nonmental health diagnosis such as pain. The rational utilized was that only
treatment listed in the DSM would be covered (DSM exclusions).

Specific practitioner/therapist exclusions

Qualifications of practitioners mandated to administer nonpharmacological
treatments (eg, manipulation and massage) added further ambiguity in
state-by-state determination of coverage. Plans typically characterized
coverage of manipulation under “chiropractic services” in summary
statements, while a number of states incorporated a distinct section on
osteopathic manual medicine—manipulation therapy performed by a doctor of
osteopathy. The opposite was true for massage, which proved to be covered
only when administered by a physical therapist or chiropractor, while
massage provided by a massage therapist was often denied.

Discussion

The EHB provision to the Affordable Care Act intended to provide individual and small
group market insurance participants health coverage in fundamentally important
areas. This was partially enacted based on prior evidence that increased coverage
may potentially improve chronic disease care and subsequent health outcomes. While health coverage has demonstrated positive effects on management of
chronic conditions such as depression, there has been little evaluation of this
potential in the setting of chronic pain. An essential first step to address this gap in the evidence was to evaluate
coverage for evidence-based chronic pain treatments.

The ACP recommendations for the treatment of chronic LBP are likely the most
prominent and influential guidelines in this area. Analysis of 2017 EHB benchmarks
for level of coverage for ACP-recommended treatments in all 50 states and the
District of Columbia distinguished several flaws. First, except for manipulation,
the evidence-based treatments recommended by the ACP guidelines are included in
fewer than 10 states’ benchmark plans. In cases where coverage was identified, caps
were often placed on the number of treatments, which may limit treatments to
adequately address chronic pain. Several recommended treatments—namely,
multidisciplinary rehabilitation, biofeedback, and CBT—were difficult to evaluate
due to inconsistent or unclear policy statements. Finally, coverage limitations
associated with chronic conditions further reduce therapeutic opportunities. Table 2 details the
aforementioned limitations in policy statements.

Table 2.

Common Limitations in State Essential Health Benefits Plans.

1. Nonrecognition of chronic pain as a distinct entity in
coverage statements
2. Noncoverage of evidence-based treatments endorsed by
published guidelines
3. Limits on the number of individual and combined visits for
rehabilitative and treatment that reduce the potential for
multidisciplinary care and rehabilitation
4. Noncoverage of behavioral treatments based on nonmental
health condition status versus evidence basis (DSM
exclusions)
5. Noncoverage of treatments based on labeling versus evidence
basis (eg, CAM exclusions)
6. Inconsistencies in coverage statements (eg, treatment covered
in 1 section but denied in others)

Abbreviations: CAM, complementary and alternative medicine; DSM,
Diagnostic and Statistical Manual of Mental Disorders.

Chronic pain is one of the most burdensome and expensive conditions plaguing the
United States. While many stakeholders have identified incorporation of
nonpharmacological treatment as a potential solution, the overall level of denial
and ambiguity related to coverage is concerning. Additionally, minimal recognition of chronic pain as a distinct entity within
policy statements illuminates a lack of awareness surrounding the condition as well
as deficits in policy support for appropriate treatments. As noted in the 2018
National Pain Strategy, coverage arrangements can “… exert powerful effects on how
pain is managed and may lead pain patients to gravitate to prescription drugs over
complementary or alternative treatments, creating risks for subsequent problems with
opioid dependency.”

Evidence-based treatments consistently change with new technology and influence the
“medically necessary” classifications at a given point in time. Accordingly, a
mechanism to periodically review translational research, clinical guidelines, and
treatments in terms of medical necessity is warranted. Since delays in therapies and
overreliance on unimodal interventions have shown to increase treatment costs and
risks, it is imperative that policy statements clearly address chronic pain and
multidisciplinary treatments to reduce this burden. In addition, socioeconomically disadvantaged individuals have demonstrated
greater reliance on EHB coverage for chronic disease care because premiums are
subsidized for eligible low-income participants in the insurance marketplaces. Rural and underserved communities appear to have much higher rates of opioid
prescriptions, opioid-related hospitalizations, and drug overdose deaths, which may
stem, in part, from the lack of nonpharmacological treatment coverage. Finally, the noncoverage of treatments based on labeling
(CAM exclusion) that is outdated and largely inconsistent
between states appears arbitrary and potentially discriminatory.

Clinical and research institutions must be strengthened to enable systematic
evaluation of evidence in the context of policy constraints and facilitate focused
interactions between researchers and policymakers. The present study validates
findings reported by previous investigations of EHB provisions and reinforces how
overarching policies hinder clinical practices. A recent review of commercial and
Medicare insurers found that while coverage was available for manipulation and
physical therapies, the majority of plans denied or lacked information on
acupuncture and psychological interventions despite supporting evidence.

Notably, expansion of coverage for these therapies may have immediate clinical and
financial benefit. Several states that do not support coverage for
nonpharmacological treatments have attempted expansion of evidence-based services.
For example, a state-funded trial expanded acupuncture coverage for chronic pain in
Vermont’s Medicaid population. This pragmatic trial found that in addition to
improved pain status, patients receiving acupuncture for chronic pain, 57% and 32%
were able to reduce nonopioid and opioid analgesics, respectively, and an additional
91% reported qualitative improvements in physical, functional/behavioral, or
psycho-emotional status. Preceding research has also revealed that initial treatments with yoga,
acupuncture, manipulation, MBSR, and CBT, in the setting of LBP are
cost-effective.,

States have recently had the option to amend their EHB offerings to reflect new
evidence-based research findings. Some states (eg, Montana) have clarified prior
discrepancies in their policies to reflect positive changes in coverage. Illinois
remains the only state that has chosen to update the 2018 policy statement, which
mandates coverage in 2020. The amendments to the Illinois policy emphasize the
importance of mental health treatments, exercise and physical reconditioning,
nutrition, as well as complementary and alternative modalities as first-line
interventions for pain management.

Despite the notable findings, limitations of this review cannot be dismissed. The EHB
present a floor and some insurance plans provide additional benefits or replace some
of the EHB services with other covered benefits. Discussions with plan
administrators to clarify areas of coverage (eg, coverage status in the individual
and small group markets despite denial in the EHB) were not included. Coverage could
also be overestimated in states that deny treatments according to specific chronic
condition criteria.

We chose to focus on treatment modalities that are often initiated and maintained by
certified modality specific practitioners which may have underestimated coverage.
For example, massage, tai chi, yoga, and MSBR were noncovered when they were
explicitly listed due to specific noncoverage statements or practitioner and
CAM-related exclusions. Because physical therapy is universally covered, many of
these specific therapies may be covered based on the training of the physical
therapist. However, the frequency and extent of incorporation as a component of
physical therapy visit could not be presently determined. Similarly, several states
cited discounts at fitness centers that could theoretically cover exercise therapies
recommended in ACP guidelines. Because the type and level of coverage and
availability could not be ascertained, they were noted as excluded and may have also
underestimated coverage. Table
3
provides recommendations for clarifying EHB benchmark plans and
increasing treatment access.

Table 3.

Essential Health Benefits Recommendations to Expand Coverage of
Nonpharmacological Therapies.

1. Inclusion of criteria and evidence standards for coverage of
nonpharmacological approaches
2. Inclusion of chronic pain as an identifier in policy
statements with discussion of how treatments differ from other
types of pain, including as follows:
 a. Acknowledgment and support for multidisciplinary care
 b. Reduced burden of cotreatment visit limitations
3. Transparent and consistent wording regarding coverage of
nonpharmacological therapies in terms of practitioner/therapist,
and number of allotted treatments
4. Avoidance of behavioral treatment for pain exclusions and
focus on coverage based on evidence of treatments for pain (eg,
MBSR, CBT, and biofeedback)
5. Avoidance of arbitrary or outdated language or labeling of
therapies with focus of coverage based on currently available
evidence (eg, CAM exclusions)
6. Avoidance of licensed practitioner-based exclusions with
focus on identification of available certified
practitioners
7. Avoidance of exercise, self-care, and stress management
exclusions and focus on coverage of identified facilities and
practitioners available to provide treatments (eg, yoga, tai
chi, MBSR)
8. Development of criteria for coverage eligibility based on
nonresponse and/or nontolerability of covered treatments similar
to tiered coverage recommendations commonly used for medication
and comprehensive recommendation that incorporate
nonpharmacological care40

Abbreviations: CAM, complementary and alternative medicine; CBT,
cognitive behavioral therapy; DSM, Diagnostic and Statistical Manual of
Mental Disorders; MBSR, mindfulness-based stress reduction.

Conclusion

Analysis of the 2017 EHB benchmark plans that represent the minimum benefits required
in all states demonstrated that, other than manipulation, there was significant lack
of coverage for nonpharmacological treatments recommended by the ACP guidelines for
chronic LBP. Although state EHB coverage policies should reflect current evidence,
our analysis reveals a disconnect between evidence-based recommendations and
official guidelines. Statements often used outdated, arbitrary, and contradictory
language to justify denial of treatments, a practice that appears to be largely
unchanged since 2017 when EHB modifications were permitted. For individuals who
depend on EHB coverage as a strong determinant of chronic pain management, it is
especially vital for states to ensure access to comprehensive options including
nonpharmacological treatments to improve the current trajectory of pain care in
America.

In anticipation of future revisions to EHB benchmark plans, states should
increasingly aim to enact policies that reflect safe, evidence-based, and
efficacious treatment options in effort to address the alarming rates of chronic
pain as well as substantial societal costs. Recommendations are provided for
revising policy statements to better reflect current evidence and suggestions for
treating chronic pain.

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