CurrentAnthemPolicy N/A

Pain Management Services

Describes Anthem health plans' coverage approach for a broad range of pain management services, notes that specific coverage, visit limits, prior authorization, and member cost shares depend on the member's specific plan, and references a partnership with Lin Health for chronic pain treatment in Maine.

Policy Summary

PayerAnthem

PolicyPain Management Services

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionVerify prior authorization and medical necessity requirements with the member's plan and apply appropriate member cost shares before providing pain management services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

15+Examples of services listed

MaineLin Health program availability

Policy summary

Anthem health plans provide comprehensive coverage for a broad range of pain management services, but exact coverage, visit limits, and member cost sharing depend on the member's specific health plan benefits. Certain services may require prior authorization and medical necessity criteria may apply.

Anthem emphasizes that the decision to prescribe opioids or alternative medications and treatments rests with the provider; member cost shares are applied based on the type of service (prescription drugs, physical therapy, acupuncture when covered, chiropractic, office visit copays, hospital, and professional surgical cost shares).

Key facts

PayerAnthem

PolicyPain Management Services

StatusCURRENT

Examples of services listed15+

Lin Health program availabilityMaine

Scope summaryDescribes Anthem health plans' coverage approach for a broad range of pain management services; specific coverage, visit limits, prior authorization, and member cost shares depend on the member's plan; references a partnership with Lin Health for chronic pain treatment in Maine.

Coverage stance and common services

General coverage statements

Coverage and limitations are determined by the member's specific health plan; medical necessity and prior authorization may apply:

ALL of the following

Coverage of services and any visit limitations depend on the member's specific health plan benefits.
Certain services may require prior authorization.
Medical necessity criteria may apply to certain pain management services.
Member cost shares applied according to service type (prescription drugs, physical therapy, acupuncture when covered, chiropractic, office visit copays, hospital and professional surgical cost shares).

Examples of nonmedication pain management services (not exhaustive)

Anthem lists the following non-medication services as commonly covered depending on plan:

ANY of the following

Acupuncture
Anesthesiology
Biofeedback
Chiropractic
Interventional pain management (includes epidural injection and nerve root block procedures)
Paravertebral facet injections
Regional Sympathetic Nerve Block

Partnership program (Maine specific)

Anthem has partnered to offer an alternative chronic pain program in Maine:

ALL of the following

Anthem partnered with Lin Health Medical Group to offer therapy and coaching for chronic pain within Maine's statewide care provider network.
Lin Health program includes one-on-one pain recovery coaching, integrative support with medical oversight, and is available in person and virtually (Portland location).
Program is presented as a low-risk alternative to opioid medication or surgery.

Actions and requirements for providers

Prior Authorization

Prior authorization may be required

Certain pain management services may require prior authorization depending on the member's specific plan — providers should verify prior auth requirements with the member's plan before providing service.

Documentation Required

Medical necessity documentation

Medical necessity criteria may apply to certain pain management services; providers should maintain documentation demonstrating medical necessity as required by the member's plan.

Billing Rule

Apply appropriate member cost shares

Providers and billing staff must apply member cost shares based on the type of service rendered (prescription drugs, physical therapy, acupuncture when covered, chiropractic, office visits, hospital, and professional surgical services) per the member's plan.

Background and program details

Anthem provides comprehensive coverage of pain management services and notes that what services are covered and any limitations on the number of covered visits depend on the member's specific plan; certain services may require prior authorization and medical necessity criteria may apply.

Plan-specific benefits determine visit limits (for example, most plans have limits on physical therapy visits though the largest-enrollment plan has unlimited visits) and member cost shares vary by service type.

Anthem has partnered with Lin Health Medical Group to offer an evidence-based chronic pain program in Maine. The Lin Health model includes one-on-one pain recovery coaching, integrative support with medical oversight, and is offered in person at a Portland location as well as virtually, providing a low-risk alternative to opioid medication or surgery.

Policy Summary

PayerAnthem

PolicyPain Management Services

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionVerify prior authorization and medical necessity requirements with the member's plan and apply appropriate member cost shares before providing pain management services.

SourceLink

On This Page

OpenPayer

Pain Management Services

Policy summary

Coverage stance and common services

Actions and requirements for providers

Background and program details

Document changes