BlueCross and BlueShield of Montana Medical Policy/Codes
Back School
Chapter: Therapies
Current Effective Date: August 27, 2013
Original Effective Date: August 27, 2013
Publish Date: August 27, 2013
Description

Back school is behavior training for the prevention and treatment of back problems arising from faulty body posture and muscular dysfunction. 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.

Policy

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.

Coverage

Back school is considered not medically necessary for the prevention and treatment of back pain.

Rationale

In 2007, G McIntosh and H. Hall completed two separate studies. The first study 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. A systematic 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 US Food and Drug Administration (FDA) and the UK Medicines and Healthcare Products Regulatory Agency (MHRA). They found 34 systematic reviews, random 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.” (3)    

In 2007, G. McIntosh and H. Hall conducted a systematic review that focused on chronic back pain. Their review searched organizations such as the FDA and the MHRA. 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 systemic 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)

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”. (5)

Professional organizations

A review of professional organizations was conducted. The American Academy of Family Physicians (AAFP) states “back schools, low-level laser therapy, lumbar supports, prolotherapy, short wave diathermy, traction, transcutaneous electrical nerve stimulation, and ultrasound have negative or conflicting evidence of effectiveness.” (6)

The American Academy of Pain Medicine (AAPM) does not mention back school as an approved treatment modality under the 2009 Pain Management Clinical Guidelines. (7)

The American Chronic Pain Association (ACPA) does not mention back school as an approved treatment modality in the 2013 Resource Guide to Chronic Pain Medication & Treatment Guidelines. (8)

A search of peer reviewed literature through August 2013 identified additional clinical trial publications. There are no additional published studies that prompt reconsideration of the current position statement.

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.

ICD-9 Codes

Not medically necessary for all diagnosis.

ICD-10 Codes

Not medically necessary for all diagnosis.

Procedural Codes: S9117
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.
  2. Back School. Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2004 April) 8.03.07.
  3. .McIntosh G, Hall H. Low back pain (acute). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2007.
  4. McIntosh G, Hall H. Low back pain (chronic). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2007.
  5. 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.
  6. Primary care interventions to prevent low back pain in adults- Recommendation statement: American Academy of Family Physicians (AAFP) 2009. Accessed September 2013. www.aafp.org .
  7. Chronic Pain Medical Treatment guidelines- Clinical guidelines. American Academy of Pain Medicine (AAPM), JULY 2009. Accessed September 2013.  www.painmed.org .
  8. ACPA Resource Guide to Chronic Pain Medication & Treatment- treatment guidelines. American Chronic Pain Association (ACPA) 2013. www.theacpa.org .
  9. Back School-Archived February 2011. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2004 February) Therapy 8.03.07.
History
August 2013  New 2013 BCBSMT medical policy.  Back school is considered not medically necessary for the prevention and treatment of back pain. 
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Back School