Medical peer review is an indispensable service for insurers to ensure that claims are justly handled, not unfairly declined and settled in a timely manner. It helps them capture independently verified data that would help demonstrate that insurance claims have been settled fairly. Typically, health insurers make their coverage decisions on the basis of the available medical evidence as regards effectiveness and safety. This evidence also incorporates the recommendations and guidelines from medical societies as well as related peer-reviewed studies. It is based on this evidence that the peer review physician appointed by the insurer evaluates the procedure / treatment for which coverage is requested. There is one field, though, for which this system does not seem to be ideal – the field of chronic pain, as pain specialists point out. Here are the reasons they give:
- Measuring the extent of pain and the effect a treatment provided has is difficult because of the subjective nature of pain. Insurance companies have policies that require doctors providing pain injections to show that the patient experienced fifty to eighty percent pain relief before providing the treatment again.
- High-quality clinical studies for pain treatments are limited. Insurance companies often want to see specific studies before approving a procedure. These studies may be expensive, require large sample sizes, and require physicians to provide half of the study with the treatment and the other half with a placebo. When patients are experiencing severe pain, the option of providing a placebo is not practical. Many patients may opt out of the clinical trials and prefer taking opioids or pay for the treatment out of their own pocket if they can afford the same.
Doctors are not usually encouraged to prescribe opioids mainly because of the risk of patients becoming addicted to it. The difficulty doctors have is that the non-opioid approaches encouraged by the CDC are difficult to implement because most of those are not covered by insurance. These options include joint injections, steroid injections, physical therapy, fluid injections, nerve blocks and radiofrequency ablation. Pain specialists are of the opinion that insurance companies have become increasingly restrictive in recent years, and this prevents doctors from providing appropriate care and treatment to their patients.
This has led to a situation where many pain doctors have started offering their treatments at “for cash” prices. This may have a negative impact because only wealthy people may be able to afford these alternative pain treatments. The average middle-class person may have to either opt for low-cost generic medications like opioids, or suffer the pain. Insurers do have an appeals process in place to ensure experimental treatments or denied treatments can be covered, provided certain conditions are met. The outcome of these appeals is largely dependent on the medical peer review involved.
In this scenario, pain management doctors urge that insurance companies provide coverage for alternative pain treatments. One such effective treatment is radio frequency ablation that used to be covered, but is now being denied coverage by many insurance companies since they consider it experimental. Anthem, United Healthcare, Aetna, some Blue Cross Blue Shield-affiliated health insurance companies, and many Medicare-contracted payers consider the usage of radio frequency ablation specifically for the sacroiliac joint (which represents around fifteen to twenty percent of all back pain) to be investigational/experimental. However, studies have shown significant levels of pain relief after using this procedure for the sacroiliac joint.
It is vital that doctors have the option to provide effective alternative pain treatments and limit the prescription of opioids. However, this can be made possible only if insurers broaden the coverage options. This is necessary both from the point of view of pain specialists who need to keep their practices open as well as from the viewpoint of patients who can undergo the best pain treatment available and live a pain-free and more constructive life.