Study Suggests Policy Terms for Nondrug Treatments for Low Back Pain Are Inconsistent

Alison Rodriguez

Insurers have inconsistent policy terms for nondrug treatments for low back pain while providing limited or no coverage for treatments that have scientific support, such as acupuncture and psychological counseling, according to researchers at Johns Hopkins Bloomberg School of Public Health.

Researchers evaluated Medicaid, Medicare, and major commercial insurers’ coverage policies in 2017 for nondrug options for treating chronic lower back pain. Specifically, the researchers examined 15 Medicaid, 15 Medicare Advantage, and 15 commercial insurer plans covering nondrug treatments for lower back pain among 16 states.

Of the 15 Medicaid plans assessed for psychological coverage, only 3 plans covered psychological interventions. The authors noted that even for physical therapy—a known method for relieving lower back pain—there were inconsistent coverage policies even when it was covered by nearly all of the plans.

"Some plans covered 2 visits, some 6, some 12; some allowed you to refer yourself for treatment, while others required referral by a doctor," senior author, Caleb Alexander, MD, MS, associate professor of epidemiology at the Bloomberg school, said in a statement. "That variation indicates a lack of consensus among insurers regarding what model coverage should be, or a lack of willingness to pay for it."  

Payers most commonly covered physical therapy (98% [44 of 45 plans]), occupational therapy (96% [43 of 45 plans]), and chiropractic care (89% [40 of 45 plans]), while transcutaneous electrical nerve stimulation (67% [10 of 15 plans]) and steroid injections (60% [9 of 15 plans]) were the most commonly covered among the therapies examined for Medicaid plans only.

Acupuncture and psychological interventions were either not covered by plans examined (67% of all plans [30 of 45] did not cover acupuncture) or lacked information about coverage (80% of Medicaid plans [12 of 15] lacked information about coverage of psychological interventions).

During the study the researchers also interviewed 43 executives who represented the plans they were assessing. The representatives indicated that their organizations have made efforts to increase access to nondrug therapies in response to the opioid epidemic; however, they suggested there is a need for better coordinated nondrug and drug coverage policies.

Wide variation in coverage of nondrug treatments for low back pain may be driven by the absence of best practices, the administrative complexities of developing and revising coverage policies, and payers’ economic incentives. 

The authors emphasized the importance of consistent policies due to the high rate of opioid overdoses. According to the study, CDC officials estimate that 49,031 Americans died from opioid overdoses in 2017.

"This study reveals an important opportunity for insurers to broaden and standardize their coverage of non-drug pain treatments to encourage their use as safer alternatives to opioids," stated Alexander.

The researchers concluded that there is room for improvement in coverage policies, such as in the expansion and standardization of nondrug treatment coverage and policy terms, which may lead to greater encouragement for nondrug treatments among patients.


Heyward J, Jones CM, Compton WM, et al. Coverage of nonpharmacologic treatments for low back pain among US public and private insurers. [published online October 5, 2018]. JAMA Network Open. doi:10.1001/jamanetworkopen.2018.3044.

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