Medical Policies - Therapy


Back School

Number:THE803.024

Effective Date:10-15-2017

Coverage:

*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

Back school is considered not medically necessary for all indications, including but not limited to the prevention and treatment of back pain or scoliosis, because it is considered to be educational or training in nature.

Description:

Back school is behavior training for the prevention and treatment of back problems. Back school is often used as an adjunct to other therapy. Prevention teaches the practice of proper body mechanics, including exercises and how to lift. Treatment includes spinal manipulative therapy and physical therapies. Back School is a rehabilitation treatment for back pain that requires patients to understand an educational message and motivate themselves to modify their behavior to prevent relapses.

Rationale:

In 2007, G McIntosh and H. Hall completed two separate systematic reviews. The first review focused on acute low back pain. Acute low back pain is usually perceived as self-limiting; however, as many as 33% of people still had moderate-intensity pain and 15% had severe pain after one year. It has a high recurrence rate; 75% of those with a first episode have a recurrence. Although acute episodes may resolve completely, they may also increase in severity and duration over time. The review was conducted to answer the following clinical questions: What are the effects of oral drug treatments for low back pain? What are the effects of local injections for low back pain? What are the effects of non-drug treatments for low back pain? The authors included harms alerts from relevant organizations such as the U.S. Food and Drug Administration (FDA) and the UK Medicines and Healthcare Products Regulatory Agency (MHRA). They found 34 systematic reviews, randomized control trials (RCTs), or observational studies that met the inclusion criteria. They performed a GRADE evaluation of the quality of evidence for interventions. In conclusion, they were able to present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics (paracetamol, opioids), back exercises, back schools, bed rest, behavioral therapy, electromyographic biofeedback, epidural corticosteroid injections, lumbar supports, massage, multidisciplinary treatment programmes, muscle relaxants, non- steroidal anti-inflammatory drugs (NSAIDs), spinal manipulation (in the short term), temperature treatments (short wave diathermy, ultrasound, ice, heat), traction, and transcutaneous electrical nerve stimulation (TENS). The authors stated, “We found insufficient evidence to judge the effectiveness of acupuncture, back schools, behavioral therapy, massage, multidisciplinary treatment programs (for either acute or subacute low back pain), or temperature treatments in treating people with acute low back pain.” (2) In 2009, G. McIntosh and H. Hall completed an update of the above systematic review focused on acute low back pain. In this systematic review the conclusion did not change from 2007. The authors reported “there remains insufficient evidence to judge the effects of this intervention” (back schools). (3)

In the second systematic review conducted by G. McIntosh and H. Hall in 2007, the focus was on chronic back pain. Their review searched organizations such as the FDA and the MHRA. (4) The authors located 74 systematic reviews, RCTs, or observational studies that met their inclusion criteria. They performed a GRADE evaluation of the quality of evidence for interventions. They presented information relating to the effectiveness and safety of the following interventions: acupuncture, analgesics, antidepressants, back schools, behavioral therapy, electromyographic biofeedback, exercise, injections (epidural steroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programs, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), spinal manipulative therapy, traction, and transcutaneous electrical nerve stimulation (TENS). The authors stated that acupuncture, back schools, behavioral therapy, and spinal manipulation may reduce pain in the short term, but it was uncertain how these compare to other active treatments. In summary, the authors concluded “We don't know whether back schools are more effective than placebo gel, waiting list, or written information at reducing pain (low-quality evidence). Compared with other treatments, we don't know whether back schools are more effective than spinal manipulation, NSAIDs, physiotherapy, callisthenics, and exercise at reducing pain (low-quality evidence)”.

The systematic review included 18 RCTS in which back school was examined as a treatment modality to improve symptoms and functional status. The authors were unable to determine if back schools are more effective than placebo gel, waiting list, or written information at reducing pain and improving function due to the low quality of evidence. They were unable to determine if back schools are more effective than spinal manipulation, NSAIDs, physiotherapy, callisthenics, and exercise at reducing pain due to the low quality of evidence. After review of multiple RCTs, there was limited evidence that support back schools improved pain and disability compared with inactive treatments to include placebo gel, waiting list, written information in the short term (6 months or less), but suggested that benefits did not persist in the longer term. The authors concluded that there is little evidence of the effectiveness of the traditional, narrow definition of back school; with the explosion in the ways in which information can be disseminated, formal back schools are far less common than in previous years. (4)

In 2009, G. McIntosh and H. Hall updated the systematic review that focused on chronic back pain. There was one systematic review and one RCT added comparing back school versus inactive control or other treatment. This review reported, “Categorisation changed from ‘likely to be beneficial’ to ‘unknown effectiveness’ owing to conflicting results and small effect sizes in the positive trials”. (5)

Tavafian, et al., completed a randomized controlled study in 2008 to examine the effects of the back school program on the quality of life in women with low back pain. One hundred and two eligible women were randomly allocated into two groups. The two groups including individuals that received the back school program plus medication (n=50) and clinic group plus medication (n = 50) and clinic group who received just medication (n = 52) were compared at 4 points in time. Data was collected at baseline and at 3, 6, and 12 months follow-up using the SF-36 questionnaire. Repeated measures analysis was performed to compare quality of life scores in 2 groups. The results identified that the quality of life scores were significantly different between 2 groups throughout the study (P < 0.0001) indicating a better quality of life among the intervention group. In conclusion, it was documented “The back school program might improve the quality of life score in women with chronic low back pain”. (6)

Professional Organizations and Practice Guidelines

National Guideline Clearinghouse (NGC)

The NGC summary for the evidence-informed primary care management of low back pain was revised in November 2011 and reports that there is insufficient evidence to recommend back schools for or against as an intervention for acute or subacute low back pain. (7)

American Pain Society (APS) and American College of Physicians (ACP)

The APS published an evidence review of guidelines for the evaluation and management of low back pain. This evidence review was published in two stages. The first stage, conducted in partnership with the ACP, was published in 2007. It focused on initial primary care evaluation and management of low back pain. The second stage, published in 2009, focused on the use of interdisciplinary rehabilitation, interventional therapies and surgery for low back pain. (8) This evidence review included the following recommendations:

“For acute low back pain, back schools were no better than advice in a single lower-quality trial (level of evidence: poor).”

“For acute or subacute low back pain, back schools were superior to placebo in a single lower-quality trial for short-term recovery and return to work, but not for pain or long-term recurrences (level of evidence: poor).”

“For acute or subacute low back pain, evidence on efficacy of back schools versus physical therapy, usual care, or advice was inconsistent, though most studies found no differences (four trials, two higher-quality) (level of evidence: fair).”

“For chronic low back pain, evidence on effects of back schools versus placebo or wait list controls is inconsistent, though most trials found no beneficial effects (level of evidence: fair).”

“For chronic low back pain, back schools are slightly superior to exercises, spinal manipulation, myofascial therapy, or advice for short-term pain and functional status, but not for long-term outcomes (level of evidence: fair).”

“More intensive back school programs based on the original Swedish program and back school programs in occupational settings appear to be the most effective (level of evidence: fair).”

“Evidence on efficacy of back schools for preventing recurrent episodes of low back pain is mixed, which may be due in part to diversity among populations and interventions evaluated. One higher-quality trial found that an intensive back school intervention decreased recurrent episodes of low back pain more than no back school through three years of follow-up, but another trial that evaluated “mini” back school found no clear effect. Three shorter-term (1 year) trials (one higher-quality) also found no effect on recurrences (level of evidence: fair).”

“One lower-quality trial found back school inferior to callisthenic exercises for reducing low back pain episodes through 12 months (level of evidence: poor).”

U.S. Agency for Health Care and Policy Research (AHCPR)

The AHCPR guidelines found that efficacy of back schools in non-occupational settings had not been proven (strength of evidence C). Strength of evidence C according to the APS evidence review represents limited research-based evidence (at least one adequate scientific study in patients with low back pain). (8)

Veterans Affairs/Department of Defense (VA/DoD)

The VA/DoD guidelines found inconclusive evidence on the long term benefit of back schools (strength of evidence: A to B). (8) Strength of evidence A according to the APS evidence review represents the following: A= Strong research-based evidence (multiple relevant and high-quality scientific studies) B= Moderate research-based evidence (one relevant, high-quality scientific study or multiple adequate scientific studies).

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

N/A

HCPCS Codes

S9117

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.

A national coverage position for Medicare may have been changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Maier-Riehle, B., and M. Harter. The effects of back schools--a meta-analysis. Internal Journal of Rehabilitation Research (2001 September); 24(3): 199-206. PMID 11560235

2. McIntosh G, Hall H. Low back pain (acute). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; October 2008. PMID 19445792

3. McIntosh G, Hall H. Low back pain (acute). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2011. PMID 215490232

4. McIntosh G, Hall H. Low back pain (chronic). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; October 2008. PMID 19445791

5. McIntosh G, Hall H. Low back pain (chronic). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; October 2010. PMID 21418678

6. Tavafian SS, Jamshidi AR, Montazeri A., A randomized study of back school in women with chronic low back pain: Quality of life at three, six, and twelve months follow-up. Spine. 2008; 33(15):1617-1621. PMID 18580739

7. National Guideline Clearinghouse (NGC). Guideline summary: Guideline for the evidence-informed primary care management of low back pain. In: National Guideline Clearinghouse (NGC). Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); Revised 2011 Nov 01. Available at < https://www.guideline.gov> (accessed - 2016 October 7).

8. American Pain Society (APS). Guideline for the Evaluation and Management of Low Back Pain. (2009). Available at <http:www.americanpainsociety.org> (accessed - 2016 October 7).

9. Back School (Archived). Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 February) Therapy 8.03.07.

Policy History:

DateReason
10/15/2017 Reviewed. No changes.
12/1/2016 Document updated with literature review. Coverage unchanged.
10/1/2015 Reviewed. No changes.
12/1/2014 Document updated with literature review. Added the following to coverage section: “Including but not limited to” and “or scoliosis, because it is considered to be educational or training in nature.” No change in the overall coverage position.
10/15/2013 Document updated with literature review. Coverage unchanged. Rationale, description, references updated.
8/15/2007 Document updated with literature review. Coverage revised, codes updated. Bit changes made. Rationale, description, reference, and title revised.
8/15/2003 New Medical Document. Revised/Updated with literature review.

Archived Document(s):

Title:Effective Date:End Date:
Back School09-15-202110-14-2022
Back School10-15-202009-14-2021
Back School10-15-201910-14-2020
Back School12-15-201810-14-2019
Back School10-15-201712-14-2018
Back School12-01-201610-14-2017
Back School10-01-201511-30-2016
Back School12-01-201409-30-2015
Back School10-15-201311-30-2014
Back School08-15-200710-14-2013
Back School08-15-200308-14-2007
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