NCD 10.4

Item/Service Description

Some hospitals also provide pain rehabilitation programs for outpatients. In such programs, services frequently are provided in group settings even though they are being furnished pursuant to each patient's individualized plan of treatment.

Indications and Limitations of Coverage

Coverage of services furnished under outpatient hospital pain rehabilitation programs, including services furnished in group settings under individualized plans of treatment, is available if the patient’s pain is attributable to a physical cause, the usual methods of treatment have not been successful in alleviating it, and a significant loss of ability by the patient to function independently has resulted from the pain. If a patient meets these conditions and the program provides services of the types discussed in §10.3, the services provided under the program may be covered. Non-covered services (e.g., vocational counseling, meals for outpatients, or acupuncture) continue to be excluded from coverage, and A/B Medicare Administrative Contractors would not be precluded from finding, in the case of particular patients, that the pain rehabilitation program is not reasonable and necessary under §1862(a)(1) of the Social Security Act for the treatment of their conditions.

Revision History

09/1988 - Clarified that services furnished under outpatient hospital pain rehabilitation programs are covered if patient's pain is attributable to a physical cause, the usual methods of treatment have not been successful in alleviating it, and a significant loss of ability by patient to function independently has resulted from the pain. Effective date NA. (TN 32)