158 Form

1

Medical Policy Outpatient Pediatric Pain Rehabilitation Centers
Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 158 BCBSA Reference Number: N/A NCD/LCD: N/A Related Policies
None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Coverage Guidelines: Outpatient Pediatric Pain Rehabilitation Centers services are covered as outlined by each Blue Cross benefit design or subscriber certificate.

Outpatient Pediatric Pain Rehabilitation Centers services are considered MEDICALLY NECESSARY when the following criteria are met:

Initial Review, All: (New episode, initial 15-day treatment)

• Clinical presentation, One: o Complex Regional Pain Syndrome (CRPS)/Reflex Sympathetic Dystrophy (RSD), All: ▪ Failed an outpatient program consisting of pain medication management, physical and/or occupational therapy, and cognitive/behavioral therapy for a minimum of 90 days ▪ Persistent pain and neurovascular symptoms that interfere with activities of daily living. o Chronic Daily Headaches, All: ▪ Chronic headache lasting hours, or continuous ▪ Headaches are of long duration (three months or longer) ▪ 15 or more headache days per month ▪ Headaches are not related to a specific underlying illness ▪ Member has been treated by a pediatric neurologist and has not improved after at least eight weeks of outpatient pharmacotherapy
▪ Able to tolerate >3 hours per day of therapy, five days per week.

2

• Age ≥7, ≤18

• Patient agrees and is able to participate in program

• Progressive therapy program, All: o Interdisciplinary program o Multiple treatment modalities for pain and functional restoration o Includes physical, occupational, and cognitive/behavioral therapy

• Goals, All: o Improve function and reduce limitation o Consistent follow-through with home treatment program

Ongoing Review, All:

• Clinical presentation, One: o Confirmed diagnosis of Complex Regional Pain Syndrome (CRPS)/Sympathetic Dystrophy (RSD) o Confirmed diagnosis of Chronic Daily Headaches

• Rehab potential based on prior level of function, with expectation for clinical or functional improvement

• Patient or caregiver is committed to program participation

• Continue teaching and evaluate knowledge retention for home Rx program

• Partial progress made in meeting treatment goals, both: o Improvement in function and reduction in limitations o Documented patient or caregiver adherence to home exercise program

Discharge Review, One:

• New onset, or worsening of Sx (symptoms) or findings, requires reassessment before continuing outpatient rehabilitation program

• Further improvement or integration of skills expected with patient or caregiver adherence to home Rx program

• Goals met, All: o Sx (symptoms) or findings, ≥ One: ▪ No longer present or new skill acquired ▪ Improved ability to manage limitations o Independent with home treatment program

• Functional plateau reached since last authorization

• Rehabilitation potential poor, ≥ One: o Chronic functional loss and maximal functional ability achieved o Lack of motivation or refusal to continue home therapy program o Unable to learn or participate in a home therapy program

Prior Authorization Information
Inpatient

3

• For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is required. Commercial PPO and Indemnity Prior authorization is required. Medicare HMO BlueSM Prior authorization is required. Medicare PPO BlueSM Prior authorization is required.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.
To ensure the service request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources Refer to our Authorization Manager page for tips, guides, and video demonstrations.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes:

Code Description 97161 Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family. 97162 Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and

4

functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family 97163 Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. 97164 Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family. 97165 Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family. 97166 Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family. 97167 Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.

5

97168 Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. ICD-10 Diagnosis Codes ICD-10-CM diagnosis codes: Code Description G44.021 Chronic cluster headache, intractable G44.029 Chronic cluster headache, not intractable G44.221 Chronic tension-type headache, intractable G44.229 Chronic tension-type headache, not intractable G56.40 Causalgia of unspecified upper limb G56.41 Causalgia of right upper limb G56.42 Causalgia of left upper limb G56.43 Causalgia of bilateral upper limbs G57.70 Causalgia of unspecified lower limb G57.71 Causalgia of right lower limb G57.72 Causalgia of left lower limb G57.73 Causalgia of bilateral lower limbs G90.511 Complex regional pain syndrome I of right upper limb G90.512 Complex regional pain syndrome I of left upper limb G90.513 Complex regional pain syndrome I of upper limb, bilateral G90.519 Complex regional pain syndrome I of unspecified upper limb G90.521 Complex regional pain syndrome I of right lower limb G90.522 Complex regional pain syndrome I of left lower limb G90.523 Complex regional pain syndrome I of lower limb, bilateral G90.529 Complex regional pain syndrome I of unspecified lower limb G90.59 Complex regional pain syndrome I of other specified site Description Level-of-Care Note A Pediatric Pain Rehabilitation Center is a facility where patients undergo intensive treatment for chronic pain. An interdisciplinary approach to pain management is used, which includes physical therapy, occupational therapy, cognitive/behavioral therapy, and medication management. Complex Regional Pain Syndrome (CRPS), formerly known as Reflex Sympathetic Dystrophy (RSD), is a condition characterized by intense, burning pain that can affect multiple areas of the body, but most often affects the hands, arms, legs, and feet. Other characteristics include stiffness, swelling, and discoloration of the affected body part.

There are two types of CRPS. Type 1 follows an illness or injury that does not directly damage the nerve area. Type 2 follows an illness or injury with distinctive nerve damage. The exact cause of CRPS is unknown.

Chronic Daily Headache is a condition when headaches occur for more than four hours per day, with 15 headache days per month, over a period of three consecutive months without an underlying illness or disease causing the headache. Headache pain is generally severe, intermittent, and migraine-like. There are four diagnostic categories: transformed migraine; chronic tension-type; new daily, persistent headache; and hemicranias continua. Associated symptoms include sleep disturbance, pain at other sites, dizziness, and psychiatric comorbidity. Medication overuse is often a contributor.

6

Policy History Date Action 9/2023 Policy clarified to include prior authorization requests using Authorization Manager.
4/2021 Clinical UM criteria on Outpatient Pediatric Pain Rehabilitation Centers moved to medical policy. New medical policy describing medically necessary indications; criteria remains unchanged. Effective 4/1/2021. 2018-2020 Outpatient Pediatric Pain Rehabilitation Centers clinical UM criteria. Review Dates: January 22, 2018; January 14, 2019; January 17, 2020. 1/2017 Outpatient Pediatric Pain Rehabilitation Centers clinical UM criteria. Original effective Date: January 1, 2017 Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Moore, Allison and Shevell, Michael; “Chronic Daily Headaches in Pediatric Neurology Practice;” Journal of Child Neurology. 2004, 19:925.
2. Pakalnis A, Butz C, Splaingard D, Kring D, Fong J.J “Emotional problems and prevalence of medication overuse in pediatric chronic daily headache,” Child Neurology, 2007 Dec; 22(12):1356- 9.doi:10.101177/0883073807307090.
3. Freedman M, Greis AC, Marino L, Sinha AN, Henstenburg J. “Complex Regional Pain Syndrome: diagnosis and treatment.” Phys Med Rehabil Clin N Am. 2014 May; 25(2):291-303.doi: 10.1016/j.pmr.2014.01.003. Epub 3/14/2014.4/2014.
4. Dhanalakshmi Koyyalagunta, MD; Gulshan Doulatram, MD; “Diagnosis and Management of Complex Regional Pain Syndrome I and II.” Orthopaedic Knowledge Online Journal Subspecialty: Pain Management, Published 5/1/2012. http://orthoportal.aaos.org/oko/article aspx?article=OKO_PAI015#article
5. Cuvellier JC, Cuisset JM, Vallée L. “Chronic daily headache in children and adolescents.” Arch Pediatr. 2008 Dec; 15(12):1805-14. doi: 10.1016/j.arcped.2008.09.017. Epub 11/1/2008.