Archived Policies - Therapy
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Work hardening programs are considered not medically necessary, as they are for the purpose of conditioning for a return to work and not for the treatment of a medical condition.
Work hardening is a highly specialized rehabilitation program that is designed to restore functional and work capacities through the application of graded work simulation. This multidisciplinary program may include physical therapy, occupational therapy, counselors, and other rehabilitation specialists. Activities are designed to improve overall physical condition, including strength, endurance, and coordination to perform a specific work activity. Tasks may also include structured work times and duties, dressing appropriately, and conducting oneself in a professional manner. (1)
The goals of work rehabilitation are to (2):
• Maximize levels of function following injury and/or illness to maintain a desired quality of life for the worker;
• Facilitate the safe and timely return of individuals to work following injury and/or illness;
• Remediate and/or prevent future injury or illness;
• Assist individuals in retaining or resuming their worker role, which can contribute to self-confidence and a view of self as a productive member in society, and prevent the negative psychosocial consequences of unemployment.
This policy was originally created in 1993 and has been updated regularly with searches of the MEDLINE database. Most recently, the literature was searched through May 2017. The following is a summary of the key literature to date.
In 2005, Beutel et al. (3) aimed to determine the impact of a vocational training program on short and long-term outcomes after psychosomatic rehabilitation. One thousand five hundred ninety (n=1,590) inpatients were screened for vocational integration. A high-risk group of 266 patients was randomly assigned to the vocational training program plus psychosomatic treatment; treatment as usual served as a control condition. An occupational training was conducted at local companies, closely integrated into psychosomatic treatment. Vocational attitudes and adjustment were studied at intake, discharge, three, 12 and 24 month follow-ups. More than half of the study participants were unemployed and/or long-term work-disabled harboring strong negative attitudes toward returning to work. Forty-six percent of the intervention group declined from participation, but complied with follow-up investigation. At discharge, participants of the vocational training program had become more optimistic regarding resuming work. At one year following discharge, participants of the training program reported less absence from work. After 24 months, vocational adjustment had improved considerably among program participants, and declined among controls and refusers. An intensive vocational training program is effective in promoting positive attitudes to work, reducing work disability and promoting return-to-work. However, a randomized design may be not optimal; evaluation necessitates long-term follow-up.
In 2005, Bonde et al. (4) believed that goal setting and motivational factors are strongly associated with maintaining a job and returning to work after sick leave, but research into the effects of interventions targeting these factors was limited. Bonde et al. conducted a randomized controlled trial (RCT) to examine the vocational effect of intervention focusing on motivation, goal setting and planning for return to work. Of 243 patients at risk of long-term sick leave or job dropout, 184 (76%) provided complete baseline information for the study. After randomization to an intervention group (n=92) and a reference group (n=92), occupational physicians examined the participants in accordance with standard guidelines. The intervention group received additional support from a social worker to enhance goal setting, motivation and planning for return to work. After 1 year 163 participants (89%) provided data on general health and employment status. The risk of not being gainfully employed was analyzed by logistic regression analysis with adjustment for several covariates. The intervention did not increase the likelihood of gainful employment after 1 year or reduce the average number of days of sick leave. The authors concluded a low-cost counselling program addressing motivation, goal setting and planning for return to work did not improve vocational outcomes or reduce sick leave among patients with work-related disorders.
In 2010, Schaafsma and colleagues (5) revaluated work conditioning, work hardening and functional restoration for workers with back and neck pain that was initially published in 2003. The authors aimed to compare the effectiveness of physical conditioning programs in reducing time lost from work for individuals with back pain. The following databases from June/July 2008 were examined: CENTRAL (The Cochrane Library 2008, issue 3), MEDLINE from 1966, EMBASE from 1980, CINAHL from 1982, PsycINFO from 1967, and PEDro. The authors focused on RCTs and cluster RCTs that studied workers with work disability related to back pain and who were included in physical conditioning programs. Two authors independently extracted data and assessed risk of bias. Thirty-seven references, reporting on 23 RCTs (3676 workers) were included, 13 of which had a low risk of bias. In 14 studies, physical conditioning programs were compared to usual care. In workers with acute back pain, there was no effect on sickness absence. For workers with subacute back pain, we found conflicting results, but subgroup analysis showed a positive effect of interventions with workplace involvement. In workers with chronic back pain, pooled results of five studies showed a small effect on sickness absence at long-term follow-up (Standardized mean difference -0.18 (95% confidence interval -0.37 to 0.00). In workers with chronic back pain, physical conditioning programs were compared to other exercise therapy in 6 studies, with conflicting results. The addition of cognitive behavioral therapy to physical conditioning programs was not more effective than the physical conditioning alone. The authors concluded the effectiveness of physical conditioning programs in reducing sick leave when compared to usual care or than other exercises in workers with back pain remains uncertain. In workers with acute back pain, these programs probably have no effect on sick leave, but there may be a positive effect on sick leave for workers with subacute and chronic back pain. Workplace involvement might improve the outcome. Better understanding of the mechanism behind physical conditioning programs and return-to-work is needed to develop more effective interventions.
In 2014, Varatharajan et al. (6) conducted a systematic review to evaluate literature on the effectiveness of work disability prevention (WDP) in workers with neck pain, whiplash-associated disorders (WAD), or upper extremity disorders. Electronic databases were searched from 1990 to 2012 and random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized and synthesized following best-evidence synthesis methodology. Of the 6,359 articles retrieved, 16 RCTs were eligible for critical appraisal and 5 were admissible. They noted a return to work coordination program (including workplace-based work hardening) was superior to clinic-based work hardening for persistent rotator cuff tendinitis. Workplace high-intensity strength training and workplace advice had similar outcomes for neck and shoulder pain. Mensendieck/Cesar postural exercises and strength and fitness exercises had similar outcomes for non-specific work-related upper limb complaints. Adding a brief job stress education program to a workplace ergonomic intervention was not beneficial for persistent upper extremity symptoms. Adding computer-prompted work breaks to ergonomic adjustments and workplace education benefited workers' recovery from recent work-related neck and upper extremity complaints. At present, no firm conclusions can be drawn regarding the effectiveness of WDP interventions for managing neck pain, WAD, and upper extremity disorders. Our review suggests a return-to-work coordination program is more effective than clinic-based work hardening. Also, adding computer-prompted breaks to ergonomic and workplace interventions benefits workers' recovery. The current quality of evidence does not allow for a definitive evaluation of the effectiveness of ergonomic interventions.
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in June 2017 did not identify any clinical trials that would likely influence this review.
Professional Guidelines and Position Statements
There were no professional guidelines or position statements found that would influence the coverage position of this medical policy.
Summary Of Evidence
Available literature involves utilizing work hardening programs in individuals with neck injuries, back pain and arthritis. Further literature focuses on the reduction of time lost from work when work hardening programs are implemented. At present, work hardening programs are considered not medically necessary, as they are for conditioning for a return to work and not for the treatment of a medical condition.
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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
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ICD-10 Diagnosis Codes
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ICD-10 Procedure Codes
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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 not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
1. Work Hardening. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. 2003. Saunders, an imprint of Elsevier, Inc (14 Jun. 2017); Available at <http://medical-dictionary.thefreedictionary.com> (accessed June 14, 2017)
2. American Occupational Therapy Association. Work rehabilitation Fact Sheet (2017). Available at <https://aota.org> (accessed June 14, 2017).
3. Beutel ME, Zwerena R, Bleichner F, et al. Vocational training integrated into inpatient psychosomatic rehabilitation-short and long-term results from a controlled study. Disabil. Rehabil (2005 August) 27(15): 891-900. PMID: 16096241
4. Bonde JP, Rasmussen MS, Hjøllund H, et al. Occupational disorders and return to work: a randomized controlled study. J. Occup. Rehabil (2005 July) 37(4): 230-5. PMID: 16024479
5. Schaafsma F, Schonstein E, Whelan KM, et al. Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Syst Rev. 2010 Jan 20; (1). PMID: 20091523
6. Varatharajan S, Côté P, Shearer HM, et al. Are work disability prevention interventions effective for the management of neck pain or upper extremity disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. J Occup Rehabil. 2014 Dec; 24(4):692-708. PMID: 24522460
7. Schonstein E, Kenny DT, Keating J, et al. Work conditioning, work hardening and functional restoration for workers with back and neck pain. Cochrane Database System Review (2003) (1):CD001822. PMID: 20091523
8. Joy JM, Lowy J, Mansoor JK, et al. Increased pain tolerance as an indicator of return to work in low-back pain injuries after work hardening. Am J Occup Ther (2001 March-April) 55(2): 200-5. PMID: 11761136
9. Koopman FS, Edelaar M, et al. Effectiveness of a multidisciplinary occupational training program for chronic low back pain: a prospective cohort study. Am J Phys Med Rehabil (2004 February) 83(2): 94-103.
10. Wilson K.B. Vocational rehabilitation acceptance in the USA: controlling for education, type of major disability, severity of disability and socioeconomic status. Disabil Rehabil (2004 February 4) 26(3): 145-56. PMID: 14754625
11. De Buck PD, Breedveld J, van der Giesen FJ, et al. A multidisciplinary job retention vocational rehabilitation program for patients with chronic rheumatic diseases: patients’ and occupational physicians’ satisfaction. Ann Rheum Dis (2004 May) 63(5): 562-8. PMID: 15082488
12. Nathell, L. Effects on sick leave of an inpatient rehabilitation programme for asthmatics in a randomized trial. Scand J Public Health (2005) 33(1): 57-64. PMID: 15764242
13. Sang LS, Ying E, et al. Outcome evaluation of work hardening program for manual workers with work-related back injury. Work (2005) 25(4):297-305. PMID: 16340106
14. de Buck PD, le Cessie S, van den Hout WB, et al. Randomized comparison of a multidisciplinary job-retention vocational rehabilitation program with usual outpatient care in patients with chronic arthritis at risk for job loss. Arthritis Rheum (2005 Oct 15) 53(5):682-90. PMID: 16208658
15. Baker P, Goodman G, Ekelman B, et al. The effectiveness of a comprehensive work hardening program as measured by lifting capacity, pain scales, and depression scores. Work (2005) 24(1):21-31. PMID: 15706069
16. van den Hout WB, de Buck PD, Vlieland TP, et al. Cost-utility analysis of a multidisciplinary job retention vocational rehabilitation program in patients with chronic arthritis at risk of job loss. Arthritis Rheum (2007 Jun 15) 57(5):778-86. PMID: 17530677
17. Work Hardening - Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual. (2003 April) Therapy 8.03.06.
|7/15/2017||Document updated with literature review. Coverage unchanged.|
|9/1/2016||Reviewed. No changes.|
|10/15/2015||Document updated with literature review. No changes.|
|9/1/2014||Reviewed. No changes.|
|12/15/2013||Document updated with literature review. Coverage unchanged. CPT/HCPCS codes updated.|
|3/1/2006||Revised/updated entire document|
|12/1/2003||Revised/updated entire document|
|1/1/1993||New medical document|
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