Medical Policies - Medicine
*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*
Hypnosis may be considered medically necessary when used to control acute or chronic pain (e.g., during dressing changes for an extensive burn patient), or as an adjunct to psychotherapy.
Hypnosis is considered experimental, investigational and/or unproven when used for anesthesia, including but not limited to use during any stage of labor.
NOTE: Hypnosis may be subject to contract limitations or exclusions. Carefully consult the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to hypnosis for any indication, including, but not limited to, hypnosis for weight management, smoking cessation.
Hypnosis is an induced state in which there is an increased amenability and responsiveness to suggestions and commands. The clinical application of hypnosis in relief of pain is directed toward controlling the pain itself and in relieving the emotional distress that the pain causes the patient. By understanding and relieving the suffering, hypnosis allows more effective control of pain.
There are several advantages in the use of psychological pain relief over somatic techniques in the management of acute and chronic pain. Hypnosis can control pain without unpleasant side effects, and can create life-enhancing attitudes in the patient. Hypnotic techniques generally include:
• Blocking awareness of pain,
• Substituting another feeling (such as pressure) for the pain,
• Moving the pain to a smaller less significant body part, OR
• Changing the meaning of the pain so it is less important.
This policy was created in September 1990 and updated periodically with literature review. The most recent search was completed through November 2017. The following is a summary of the key literature.
Pain is one of the most common, burdensome, and feared symptoms experienced by individuals diagnosed with cancer. The American Pain Society (APS) standard for pain management in cancer recommends both pharmacologic and psychosocial approaches. To obtain a current, stable, and comprehensive estimate of the effect of psychosocial intervention on pain, Sheinfeld and colleagues (28) conducted a meta-analysis of RCT’s among adult patients with cancer published between 1966 and 2010. Three pairs of raters independently reviewed 1681 abstracts, with a systematic process for reconciling disagreement, yielding 42 papers, of which 37 had sufficient data for meta-analysis. Studies were assessed for quality using a modified 7 item physiotherapy evidence database (PEDro) coding scheme. Pain severity and interference were primary outcome measures. Study participants (N=4199) were primarily women (66%) and Caucasian (72%). The weighted averaged effect size across studies for pain severity (38 comparisons) was 0.34 (95% CI, 0.23 to 0.46; P<.001), and the effect size for pain interference (4 comparisons) was 0.40 (95% CI, 0.21 to 0.60; P<.001). Studies that monitored whether treatment was delivered as intended had larger effects than those that did not (P=.04). The authors concluded that psychosocial interventions have a medium-size effect on both pain severity and interference. These robust findings support the systematic implementation of quality-controlled psychosocial interventions as part of a multimodal approach to the management of pain in patients with cancer.
In 2013, Werner et al. (29) completed an RCT to evaluate the use of self-hypnosis to cope with labor pain. The objective was to estimate the use of epidural analgesia and experienced pain during childbirth after a short antenatal training course in self-hypnosisto ease childbirth. This was a randomized, controlled, single-blinded trial using a 3-arm design conducted during July 2009 until August 2011 and involved a total of 1222 healthy nulliparous women. Use of epidural analgesia and self-reported pain during delivery was compared in 3 groups: a hypnosisgroup receiving three 1-hour lessons in self-hypnosiswith additional audio recordings to ease childbirth, a relaxation group receiving three 1-hour lessons in various relaxation methods and mindfulness with audio recordings for additional training, and a group receiving standard antenatal care only. Use of epidural analgesia was the primary outcome and the secondary outcome includedself-reported pain. There were no between-group differences in use of epidural analgesia-31.2% (95% confidence interval [CI] 27.1-35.3) in thehypnosisgroup, 29.8% (95% CI 25.7-33.8) in the relaxation group and 30.0% (95% CI 24.0-36.0) in the control group. No statistically significant differences between the three groups were observed for any of the self-reported pain measures. The trial determined that there was no difference across the study groups in use of epidural analgesia or pain experience. Further studies are warranted with focus on specific subgroups.
Shakibaei et al. (30) examined the effects of hypnosis on both pain and re-experiencing of trauma in burn patients. Forty-four patients hospitalized for burn care were randomly assigned to either hypnotherapy or a control group. Direct and indirect hypnotic suggestions were used to reduce pain and reexperiencing of trauma. All patients received routine burn care. Pain reports were quantified by using a self-report numeric rating scale ranging from 0 to 5. The number of recalled vivid, troubling events of the trauma in 24-hour intervals was used for rating the reexperiencing of trauma. The hypnotherapy group showed significantly lower pain ratings than the control group and reported a significant reduction in pain from baseline. There was a significant reduction in trauma reexperience scores in the hypnotherapy group but not the control group. The findings support the efficacy of hypnotherapy in the management of both pain and reexperiencing of trauma in burn patients.
Practice Guidelines and Position Statements
The 2017 National Comprehensive Cancer Network (NCCN) Guideline for Adult Cancer Pain (31) considers integrative interventions in conjunction with pharmacologic interventions as needed. The interventions may be especially important in the vulnerable population (e.g., frail, elderly, pediatric) whom standard pharmacologic interventions may be less tolerated, or based on patient preference. The NCCN guideline recognizes hypnosis as a cognitive treatment modality.
The 2017 American Chronic Pain Association (ACPA) Resource Guide to Chronic Pain states complementary and alternative medicine (CAM) includes a diverse group of healing systems, practices, and products that are not part of conventional medicine. Some modalities have proven scientific validity and have become mainstream (i.e., acupuncture, meditation, hypnosis, yoga, certain herbal preparations, etc.). Other CAM approaches have strong followers, but their “proof” of value is really anecdotal rather than based on scientific fact. (32)
Literature confirms that hypnosis continues to be recognized when used to control acute or chronic pain, or as an adjunct to psychotherapy. Currently, there is a lack of clinical data establishing that the use of hypnosis for anesthesia improves health outcomes. Hypnosis is considered experimental, investigational and/or unproven when used for anesthesia, including but not limited to use during any stage of labor.
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.
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.
The following codes may be applicable to this Medical policy and may not be all inclusive.
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
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>.
1. Holroyd J. Hypnosis treatment of clinical pain: understanding why hypnosis is useful. Int J of Clin Exp Hypn. Jan 1996; 44(1):33-51. PMID 8582777
2. Patterson DR, Goldberg ML, Ehde DM. Hypnosis in the treatment of patients with severe burns. Am J Clin Hypn. Jan 1996; 38(3): pages 200-212; discussion page 213. PMID 8712163
3. Wallace B, Allen PA, Propper RE. Hypnotic susceptibility, imaging ability, and anagram-solving activity. Int J of Clin Exp Hypn. Oct 1996; 44(4):324-37. PMID 8885531
4. Martin DJ, Lynn SJ. The Hypnotic Simulation Index: successful discrimination of real versus simulating participants. Int J of Clin Exp Hypn. Oct 1996; 44(4):338-53. PMID 8885532
5. Lynch DF Jr. Empowering the patient: hypnosis in the management of cancer, surgical diseases and chronic pain. Am J Clin Hypn. Oct 1999; 42(2):122-30. PMID 10624023
6. Benhaiem JM, Attal N, Chauvin M, et al. Local and remote effects of hypnotic suggestions of analgesia. Pain. Jan 2001; 89(2-3):167-73. PMID 11166472
7. Wright BR, Drummond PD. The effect of Rapid Induction Analgesia on subjective pain ratings and pain tolerance. Int J of Clin Exp Hypn. Apr 2001; 49(2):109-22. PMID 11294115
8. Lu DP, Lu GP, Kleinman L. Acupuncture and clinical hypnosis for facial and head and neck pain: a single crossover comparison. Am J Clin Hypn. Oct 2001; 44(2):141-8. PMID 11591081
9. Frenay MC, Faymonville ME, Devlieger S, et al. Psychological approaches during dressing changes of burned patients: a prospective randomized study comparing hypnosis against stress reducing strategy. Burns. Dec 2001; 27(8):793-9. PMID 11718981
10. Ray WJ, Keil A, Mikuteit A, et al. High resolution EEG indicators for pain response in relation to hypnotic susceptibility and suggestion. Biol Psychol. 2002; 60(1):17-36. PMID 12100843
11. Montgomery GH, David D, Winkel G, et al. The effectiveness of adjunctive hypnosis with surgical patients: a meta-analysis. Anesth Analg. Jun 2002; 94(6):1639-45. PMID 12032044
12. Hermes D, Trubger D, Hakim SG, et al. Perioperative use of medical hypnosis. Therapy options for anasthesists and surgeons. Anaesthesist. Apr 2004; 53(4):326-33. PMID 15088095
13. Araoz D. Defining hypnosis. Am J Clin Hypn. Jan 2005; 48(2-3):123-6. PMID 16482836
14. Butler LD, Symons BK, Henderson SL, et al. Hypnosis reduces distress and duration of an invasive medical procedure for children. Pediatrics. Jan 2005; 115(1):e77-85. PMID 15629969
15. Raij TT, Numminen J, Narvanen S, et al. Brain correlates of subjective reality of physically and psychologically induced pain. Proc Natl Acad Sci USA. Feb 2005; 102(6):2147-51. PMID 15684052
16. Milling LS, Kirsch I, Allen GJ, et al. The effects of hypnotic and nonhypnotic imaginative suggestion on pain. Ann Behav Med. Apr 2005; 29(2):116-27. PMID 15823785
17. Jensen MP, Patterson DR. Control conditions in hypnotic-analgesia clinical trials: challenges and recommendations. Intl J Clin Hypn. Apr 2005; 53(2):170-97. PMID 16028332
18. Stewart JH. Hypnosis in contemporary medicine. Mayo Clinic Proceedings. Apr 2005; 80(4):511-24. PMID 15819289
19. Jenson MP, Hanley MA, Engel JM, et al. Hypnotic analgesia for chronic pain in persons with disabilities: a case series. Int J Clin Hypn. Apr 2005; 53(2):198-228. PMID 16025734
20. Rainville P, Bao QV, Chretien P. Pain-related emotions modulate experimental pain perception and autonomic responses. Pain. Dec 5, 2005; 118(3):306-18. PMID 16289802
21. Schupp CJ, Berbaum K, Berbaum M, et al. Pain and anxiety during interventional radiologic procedures: effect of patients’ state of anxiety at baseline and modulation by nonpharmacologic analgesia adjuncts. J Vasc Interv Radiol. Dec 2005; 16(12):1585-92. PMID 16371522
22. Richardson J, Smith JE, McCall G, et al. Hypnosis for procedure-related pain and distress in pediatric cancer patients: a systematic review of effectiveness and methodology related to hypnosis interventions. J Pain Symptom Manage. Jan 2006; 31(1):70-84. PMID 16442484
23. Jensen M, Patterson DR. Hypnotic treatment of chronic pain. J Behav Med. Feb 2006; 29(1):95-124. PMID 16404678
24. Patterson DR, Wiechman SA, Jensen M, et al. Hypnosis delivered through immersive virtual reality for burn pain: A clinical case series. Int J of Clin Exp Hypn. Apr 2006; 54(2):130-42. PMID 16581687
25. Milling LS, Reardon JM, Carosella GM. Mediation and moderation of psychological pain treatments: response expectations and hypnotic suggestibility. J Consult and Clin Psychol. Apr 2006; 74(2):253-62. PMID 16649870
26. Liossi C, White P, Hatira P. Randomized clinical trial of local anesthetic versus a combination of local anesthetic with self-hypnosis in the management of pediatric procedure-related pain. Health Psychol. May 2006; 25(3):307-15. PMID 16719602
27. Osborne TL, Raiche KA, Jensen MP. Psychologic interventions for chronic pain. Phys Med Rehabil Clin N Am. May 2006; 17(2):415-33. PMID 16616275
28. Sheinfeld Gorin S, Krebs P, Badr H, et al. Meta-analysis of psychosocial interventions to reduce pain in patients with cancer. J Clin Oncol. February 2012; 30(5):539-47. PMID 22253460
29. Werner A, Uldbjerg N, Zachariae R, et al. Self-hypnosis for coping with labor pain: a randomized controlled trial. BJOG. Feb 2013; 120(3):346-53. PMID 23190251
30. Shakibaei F, Harandi AA, Gholamrezaei A, et al. Hypnotherapy in management of pain and reexperiencing of trauma in burn patients. Int J of Clin Exp Hypn. Apr 2008; 56(2):185-97. PMID 18307128
31. National Comprehensive Cancer Network. NCCN Clinical Practice Guideline in Adult Cancer Pain. V2.2017. Available online at <https://www.nccn.org> (accessed November 27, 2017).
32. American Chronic Pain Association. ACPA Resource Guide to Chronic Pain Management: An Integrated Guide to Medical, Interventional, Behavioral, Pharmacologic and Rehabilitation Therapies. 2017 Edition. Available online at <https://www.theacpa.org> (accessed November 27, 2017).
33. Hypnosis-Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 January) Medicine 2.01.06.
|10/1/2018||Reviewed. No changes.|
|1/15/2018||Document updated with literature review. Coverage unchanged.|
|12/15/2016||Reviewed. No changes.|
|6/1/2015||Document updated with literature review. Coverage unchanged.|
|7/15/2014||Reviewed. No changes.|
|12/15/2013||Document updated with literature review. Coverage unchanged.|
|4/15/2008||Policy reviewed without literature review; new review date only. This policy is no longer scheduled for routine literature review and update.|
|10/1/2006||Revised/updated entire document|
|3/1/2000||Revised/updated entire document|
|11/1/1997||Revised/updated entire document|
|9/1/1996||Revised/updated entire document|
|5/1/1996||Revised/updated entire document|
|5/1/1990||New medical document|