13 CSR 70-3.300 - Complementary Health and Alternative Therapies for Chronic Pain Management
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, cognitive-behavioral 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.
Notes
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