Oct 21st 2021

Benefit Structure and Medical Necessity in Musculoskeletal Care

How coverage and clinical appropriateness can promote optimal treatment

Many people suffer from musculoskeletal conditions, which include carpal tunnel syndrome, low back injuries, osteoarthritis, and many more. In fact, painful musculoskeletal conditions are the leading cause of disability in the United States, affecting at least half of the adult population. Musculoskeletal pain and discomfort can range from relatively mild to extremely painful, and everything in between; all can affect a person's ability to comfortably perform their activities of daily living. In addition, patients suffering from musculoskeletal pain who receive opioids for pain management are at risk of becoming dependent on painkillers and are predisposed to additional health issues.

Musculoskeletal conditions are costly, too. Musculoskeletal pain and activity limitations result in 216 million lost workdays per year, according to a study published in the North Carolina Medical Journal. That is almost twice the staggering cost of treating the conditions themselves, which stands at over $325 billion annually in the United States (boneandjointburden.org).

As there is a wide variety of things that can go wrong with the body's muscles, cartilage, tendons, joints, and spinal discs, there is also a wide variety in how health insurance plans pay for treating musculoskeletal conditions. Variations in benefit structure can have a demonstrable impact on access to appropriate care.

For example, health plans exhibit a variety of approaches to what they will offer regarding conservative treatments for lower back pain and other non-surgical musculoskeletal conditions. One employer-sponsored health plan might cover a certain number of visits to a physical therapist for one specific diagnosis, while another plan might cover more—or fewer diagnoses.  Some health plans may work with providers to encourage use of educational and self-care resources, while others may lack this feature entirely.

Variation in health plans’ coverage of non-surgical treatments for painful musculoskeletal conditions can hinge on the following.

·       The type of care provided. Coverage may include access to various types of conservative treatments, such as physical therapy, occupational therapy, or chiropractic care. Patients may not be aware of additional benefits for acupuncture or massage therapy.

·       The number and duration of visits allowed. The Affordable Care Act in 2010 mandated 10 essential health benefits (EHBs) which required insurance plans to include coverage of “rehabilitative and habilitative services” in some form. There may be limitations on the number of visits covered in totality, or the number provided for a specific diagnosis or impaired body part. Limits can also pertain to whether these visits are medically necessary according to evidence-based guidelines. Of course, these also may not apply broadly to every single health insurance policy available. Additionally, the duration of treatment and care is typically established by the provider of physical medicine services, based on the patient’s condition. The patient’s response to the care provided determines the intensity and frequency of additional physical therapy services.

·      Where the care is delivered.  The location at which a patient receives care can determine the extent that health insurance covers the associated costs of care. For example, non-emergent care accessed in an inpatient or outpatient hospital setting may be excluded from coverage. Care provided in higher acuity settings such as a hospital can result in patients being responsible for higher out-of-pocket costs.

·       Telemedicine. The coverage of telemedicine by health plans can vary and differ from the coverage for in-person care.

Medical necessity and coverage for musculoskeletal conditions

To a large degree, coverage for musculoskeletal conditions (and the extent of coverage) may also depend on whether treatment for a condition is medically necessary.

Healthcare.gov defines “medically necessary" as “health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine." Payment of claims by both Medicare and private insurance payers is often determined by whether or not the services are deemed as medically necessary.

The reason this requirement exists is to ensure that treatment is aligned with the most up-to-date evidence-based medicine and that patients receive the best possible care. Ideally, a treatment that has been recognized as “medically necessary" would lead to the most optimal outcome and help minimize unnecessary and inappropriate care.

The determination of medical necessity can be complicated since many common treatments may lack the justification of evidence-based studies. Even today, the definition of medical necessity can vary slightly from insurer to insurer.

For example, what is determined to be medically necessary for Medicaid can vary from state to state. In Alaska, Medicaid will cover a variety of services for members under 21 if a screening determines a need. These services include chiropractic services, physical therapy, and occupational therapy. However, in Delaware, medical necessity is determined by a variety of criteria, including at least one criterion acknowledging cost: “Be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of program funds."

Patients may not fully understand the nuances of coverage for painful musculoskeletal conditions due to the complexity and variability of determining medical necessity for prescribed services. A doctor's approval or request for a test or treatment might be the first step, but it doesn't always guarantee coverage.  Patients should not be expected to endure the impact of unexpected financial responsibility for treatment while enduring the pain from their musculoskeletal condition. Health plan representatives and human resources staff can clearly communicate any limitations in coverage with employees who are enrolled in an employer-sponsored health plan.

To avoid unexpected out-of-pocket expenses, employees enrolled in employer-sponsored health plans should confirm coverage for services prescribed by their treating physician prior to receiving those services.

To summarize, many people suffer from musculoskeletal pain and discomfort, but what's covered can often vary from plan to plan. Understanding which services are covered by insurance and which are not can be key to ensuring you receive evidence-based medicine at the right time and interval(s) while maximizing your benefits.