OBJECTIVES: Nearly 6% of adults in the United States are affected by lower back pain (LBP) at any one time, with a lifetime prevalence in adults as high as 70% or greater. This translates to an economic burden of more than $100 billion from LBP (a third from direct medical costs), with 75%-90% contributed by chronic LBP. In addition, as much as 60% of patients experiencing a LBP episode will suffer a recurrence within a year, 45% a second recurrence within 4 years, and 15% will progress to permanent disability. Given the clinical and economic burden of LBP, heavy use of potentially addictive opioid pain medications in this population, peer-reviewed studies indicating utility of exercise regimens for treating LBP and/or preventing recurrence and progression, we evaluated payer coverage of exercise programs to address the burden of LBP.

METHODS: We reviewed coverage policies across more than 50 national and regional commercial health plans, and Medicare addressing LBP treatment and exercise regimens, and characterized payer coverage of rehabilitative and preventative exercise programs for LBP, and any policy-supporting rationale provided.

RESULTS: More than 50% of payer coverage policies recommended exercise regimens as an important option to address LBP, and/or a necessary requirement prior to progressing to more costly and invasive treatment options such as a formal plan of physical therapy (PT) of limited duration and sessions, chronic steroid administration, opioid-based pain medication use, and/or surgical interventions. While recommended and often required before progressing to other options, virtually no health plan covered supervised/ structured exercise ongoing non-PT regimens of any kind for treating existing LBP or preventing LBP recurrence, despite studies supporting such approaches.

CONCLUSIONS: While exercise regimen-based treatment of LBP is routinely excluded from coverage, there may be specific reasons for exclusion, and potential solutions to address such reasons are discussed.