Does My Health Insurance Cover Non-Drug Treatment for Pain?
Pain management is a necessary component of treatment after an orthopedic trauma or surgery. Pain is a disability that inhibits rehabilitation and limits one’s ability to return to the activities of daily living. Most health plans cover the treatment of pain resulting from illness or injury, but how they choose to cover it is another matter. Opioids are a primary treatment for pain, but they are prone to misuse and addiction, and even the proper use of opioids comes with debilitating side effects for many. Long-term use of opioids to treat chronic pain can result in chemical dependence and cause users to turn to illicit substances. The risks of accidental overdose and death from opioids are also ever-present. Indeed, opioids take the lives of 42,000 people in the U.S. every year.
Alternatives to opioids do exist, and patients might want to take advantage of these alternatives for a number of valid reasons, including avoiding drug dependence or the loss of functioning and quality of life that can accompany long-term opioid use. Examples of non-drug approaches to pain management include:
- Steroid injections
- Physical therapy
- Chiropractic therapy
- Acupuncture
- Counseling
- Surgical interventions
Medications and physical therapy are both routinely prescribed and readily approved by most health plans. Whether the insurer will cover alternative treatments varies from insurer to insurer and plan to plan and can depend heavily on the facts of the patient’s specific situation. Often, health insurers will only cover alternative treatments for chronic pain that has lasted for a significant period, such as six months or more, and has not responded to more conservative (read: cheaper) forms of treatment, such as physical therapy or drugs. Importantly, health plans often require that alternative treatments be doctor-prescribed and “medically necessary.”
“Medical necessity” is a key phrase to watch out for in any health insurance document or communication, because it is one of the most frequent (and frequently litigated) grounds offered by insurers when they deny a claim. When the insurance company denies coverage on medical necessity grounds, it’s probably time to get a lawyer. Appealing these denials can be highly technical, involving not only medical evidence but also an in-depth understanding of byzantine insurance policies and procedures. Critically, the way you handle an insurance company’s internal appeals process can control whether and how you can pursue a coverage denial in court.
Another interesting area of pain management therapy involves electrical stimulation of the nerves. Procedures and devices such as extracorporeal shockwave treatment, spinal cord stimulators and percutaneous neuromodulation therapy (PNT) sound exotic, but many are FDA-approved and have been used in clinical settings for years. It can be a wonder, then, that many health insurers still deny requests for the use of such treatment on the grounds it is investigational or experimental.
Like saying a procedure is not “medically necessary,” claiming that a treatment is “experimental” or “investigational” are the other leading rationales insurers put forward to deny coverage of a claim. For some treatments, insurance companies issue “clinical policy bulletins” that amount to a blanket denial of the treatment in all instances, relying on the “experimental” or “investigational” rationale. As noted, these statements are often simply not true. Moreover, insurance companies should evaluate any doctor-recommended request for treatment on an individual patient basis to determine if the treatment is beneficial for the particular policyholder. Blanket exclusions don’t serve the patient adequately when it comes to health care. Like “medical necessity” denials, denials based on claims of “experimental” or “investigational” are best appealed by experienced insurance law attorneys.
You have a right to have treatment for pain covered by your insurance policy, and you might have justifiable reasons to prefer non-drug treatments. Your insurance company owes it to you to evaluate your request and make a decision based on your health needs, not the insurer’s economic bottom line.
