Complementary Health and Alternative Therapies for Chronic Pain Management

PURPOSE: This rule establishes the MO HealthNet payment policy for the complementary health and alternative therapies for chronic pain management for adult Medicaid participants. The goal of this policy is to improve health outcomes and decrease opioid use by adult participants to manage chronic pain. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Administration. (A) This rule governs the practice of complementary health and alternative therapy for adult participants as a covered MO HealthNet benefit. The intent of this regulation is to provide complementary health and alternative therapy, coordinated by the prescribing physician, in an effort to provide alternatives to opioid use for the treatment of chronic pain, reduce opioid misuse, improve MO HealthNet participants’ chronic pain management skills, reduce avoidable costs, and improve health outcomes. (B) Complementary health and alternative therapy for chronic pain management shall be administered by the Department of Social Services, MO HealthNet Division. The services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the division and shall be included in the MO HealthNet Physician Provider Manual, which is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website http://www.dss.mo.gov/mhd on August 15, 2018. This rule does not incorporate any subsequent amendments or additions. (C) The following definitions will be used in administering this rule: 1. “Adult participant” means a person who is at least twenty-one (21) years of age or older and who is enrolled as a MO HealthNet participant; 2. “Complementary health and alternative therapy for chronic pain” combines the use of physical therapy, cognitivebehavioral therapy, chiropractic therapy, and/or acupuncture to promote chronic pain relief for adult participants; 3. “Physical therapy treatment for chronic pain” includes, but is not limited to, participant education and counseling, manual techniques, therapeutic exercises, electrotherapy, and massage; 4. “Cognitive-behavioral therapy for chronic pain” or “CBT” combines treatment of emotional thinking and behavioral health for participants with chronic pain, trains in behavioral techniques, and helps patients modify situational factors and cognitive processes that exacerbate pain; 5. “Chiropractic therapy for the treatment of chronic pain” may include, but is not limited to, spinal manipulation or spinal adjustment, and as further defined by section 331.010.1, RSMo; 6. “Acupuncture” involves the use of needles inserted into the body by piercing of the skin and other modalities as defined by sections 331.030.8 and 324.475(1), RSMo; 7. “Prescribing physician” means a physician licensed under Chapter 334, RSMo, who specializes in family medicine or internal medicine and is authorized to prescribe medication or other therapy within the scope of such person’s practice; 8. “Complementary health and alternative therapy provider” means a complementary health and alternative therapy care provider licensed by the state of Missouri and authorized to provide health care services within the scope of such person’s practice; 9. “First-line non-opioid medication therapy” includes, but is not limited to, analgesics such as non-steroidal antiinflammatory drugs (NSAIDs), acetaminophen, cyclooxygenase 2 (COX-2) inhibitors, SAM-E herbal therapy, topical analgesics, selected antidepressants, selected anticonvulsants, and/or muscle relaxer medication; 10. “Opioid medication therapy” includes any prescription drug, natural or synthetic, that binds to the brain’s opioid receptors having an addiction-forming or addiction-sustaining ability, or being capable of conversion into a drug having such addiction-forming or addiction-sustaining ability; 11. “Chronic pain” means a non-cancer, non-end-of-life pain lasting more than three (3) months, or longer than the duration of normal tissue healing; 12. “Acute pain” means pain, whether resulting from disease, accidental or intentional trauma, or other cause that the practitioner reasonably expects to last only a short period of time. Acute pain does not include chronic pain, pain being treated as part of cancer care, hospice or other end of life care, or pain being treated as part of palliative care; and 13. “High dose opioid therapy” is to be considered as any therapy greater than ninety (>90) MME (morphine milligram equivalents) per day. (2) Covered Services and Limitations of Complementary Health and Alternative Therapy for Chronic Pain Management. (A) Participant eligibility. 1. To qualify for complementary health and alternative therapy for chronic pain, a MO HealthNet participant must be an adult participant with— A. Chronic, non-cancer neck and/or back pain; or B. Chronic pain post traumatic injury, such as traumatic injury resulting from a motor vehicle collision; or C. Other chronic pain conditions as medically necessary. 2. A prescribing physician’s referral to a complementary and alternative therapy provider is necessary for the adult participant to be eligible for complementary health and alternative therapy for chronic pain. The prescribing physician must prescribe the complementary health and alternative therapy in the adult participant’s plan of care during a regular in-office visit. (B) Provider qualifications. 1. To refer or provide complementary health and alternative therapy, the prescribing physician and the complementary health and alternative therapy provider must be currently enrolled as a MO HealthNet provider and currently licensed in Missouri or a bordering state to provide therapy. 2. Both the prescribing physician and the complementary health and alternative therapy provider must meet the provider qualifications outlined in this regulation to deliver and bill for the service. (C) Medical Services for Complementary Health and Alternative Therapy for Chronic Pain Management. 1. Adult participants may be referred by the prescribing physician for complementary health and alternative therapy to treat and manage chronic back pain, chronic neck pain, chronic pain resulting from a post-traumatic injury, or other chronic pain conditions as medically necessary. 2. The prescribing physician must seek prior authorization from the MO HealthNet Division prior to the adult participant starting complementary health and alternative therapy. 3. A prescribing physician’s referral to a complementary and alternative therapy provider is necessary for the adult participant to be eligible for complementary health and alternative therapy. 4. The prescribing physician will perform an initial assessment and provide the adult participant evidence-based education regarding pain management during the adult participant’s regular in-office visit. 5. The prescribing physician shall evaluate adult participants in the initial assessment for any potentially serious condition and refer the adult participant for further evaluation and/or diagnostic testing as medically necessary. 6. The prescribing physician shall document the injury, all tried and failed treatments, and shall submit any supporting documentation establishing that chronic pain treatment, or whether further chronic pain treatment, is medically necessary. 7. The prescribing physician will work in conjunction with the complementary health and alternative therapy provider(s) to make recommendations regarding medically necessary services based on clinical criteria and the adult participant’s risk. 8. Covered Services and Limitations. A. Complementary health and alternative therapy services for qualified adult participants requires a determination by the prescribing physician of a combination of physical therapy, chiropractic therapy, acupuncture, and non-opioid medication therapy, as clinically appropriate. B. Complementary health and alternative therapy services shall be structured according to the prescribing physician’s preference, but with an allowable maximum of thirty (30) total visits or one hundred twenty (120) units per year, and with one (1) unit equaling fifteen (15) minutes in combination of therapy defined by the prescribing physician. The prescribing physician shall reassess evidence of the adult participant’s improvement and the risks of complementary health and alternative therapy when considering discontinuing or requesting further coverage of complementary health and alternative therapies for chronic pain. C. An annual maximum of cognitive-behavioral health visits are to be determined based upon best practice and evidence-based guidelines and are listed in the MO HealthNet Physician Provider’s Manual. 9. Non-opioid and opioid therapy for chronic pain shall include initiating the first-line of non-opioid treatment, use of alternative pain therapy, establishing treatment goals, the use of opioids as supported by clinical guidelines, and the implementation of a tapering plan and schedule as clinically appropriate based upon the adult participant’s clinical presentation. The prescribing physician shall document in the patient’s medical record the method of tapering, progress, and challenges that may require intervention for participants currently receiving long-term opioid medications and/or high dose opioids on a clinically appropriate tapering plan. 10. Cognitive behavioral therapy for each adult participant must be re-assessed by a cognitive-behavioral therapy provider every ninety (90) days for continuation of care, including assessment of any impacts on the participant’s ability to work and function, increased self-efficacy, or other clinically significant improvement. 11. The prescribing physician and the complementary health and alternative therapy provider shall reassess and evaluate the risks and benefits to the adult participant of any complementary and alternative therapies and whether the therapies continue to be medically necessary to continuing treatment, requesting further treatment, and/or discontinuing treatment as medically necessary. A. Provider(s) of complementary health and alternative therapy will make recommendations for a treatment plan, continuation of services, and the final determination of care. B. The complementary health and alternative therapy must be deemed medically necessary. (3) Reimbursement Methodology. (A) Effective for dates of service beginning February 18, 2019, complementary health and alternative therapy for chronic pain management services will be paid at the Medicaid fee schedule and will be published at https://dss.mo.gov/mhd/ providers/fee-for-service-providers.htm under “Fee Schedules & Rate Lists,” which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109 as of November 13, 2018. This rule does not incorporate any subsequent amendments or additions. This fee schedule is calculated based on 62.5% of the Medicare physician fee schedule rates for physical therapy, acupuncture, and chiropractic services using MO Locality 01 as updated August 28, 2018. (B) Reimbursement shall only be made for services authorized by the MO HealthNet Division or its designee. AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2018.* Original rule filed Aug. 15, 2018, effective March 30, 2019. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.