OBJECTIVES : Given the opioid epidemic, we sought to examine coverage policies for non-pharmacologic treatments for low back pain among commercial, Medicaid, and Medicare Advantage insurers in the U.S.

METHODS : We conducted a cross-sectional analysis of publicly available policy documents from 2017 from 15 commercial, 15 Medicaid, and 15 Medicare Advantage plans. Representative plans were selected to achieve diversity in state geographic region, population, and wealth while maximizing number of covered lives examined. We focused on 5 treatments across insurers and 6 additional treatments for Medicaid beneficiaries. Documents were reviewed and abstracted by a single reviewer; a second reviewer validated a 20% sample with inter-rater agreement exceeding 95%. To supplement the data extraction and aid interpretation, we conducted key informant interviews with 20 senior executives from representative plans.

RESULTS : Physical therapy, occupational therapy, and chiropractic care were most commonly covered across all payers, while TENS and steroid injections were most commonly covered among the therapies examined for Medicaid plans only. Despite evidence to support use of acupuncture and psychological therapies, we did not find evidence of coverage by the plans we examined. Utilization management tools, such as prior authorization, were common but varied substantially with respect to appropriate conditions and providers as well as the specific quantity or duration of services permitted. Interviews with plan executives indicated a low level of coordination between coverage policies for pharmacologic and non-pharmacologic treatments.

CONCLUSIONS : In this analysis of a diverse, nationwide sample of public and private payers, we found that most payers cover physical and occupational therapy for chronic pain, with less consistent coverage of other treatments. Variation between plans in coverage of non-pharmacologic treatments for low back pain may be driven by several factors, including the absence of best practices, and suggests an important opportunity to improve the quality of care provided for chronic non-cancer pain.