Kenneth Casey, MD, FACS
There is good news on the horizon finally for folks with chronic pain.
The International Classification of Diseases – 11 (ICD11) has listed a new code for chronic pain. Previously, chronic pain had its own single designator in the ICD10 which was G89.4. This was titled “chronic primary pain”, and unfortunately, included a hodgepodge of conditions lumped together; for example, facial pain and chronic regional pain syndrome (which are not at all the same). In the new ICD classification, which takes effect in January of 2022, there are several subcategories; these include:
1) chronic cancer-related pain,
2) chronic postsurgical or posttraumatic pain (which would be an example for chronic regional pain syndrome),
3) chronic neuropathic pain,
4) chronic secondary headache or orofacial pain, (either of which would allow for classification of trigeminal neuralgia),
5) chronic secondary visceral pain (for unexplained pelvic pain),
6) chronic secondary musculoskeletal pain.
This is described in detail in the January 2019 Journal Pain.
For the estimated 25 million Americans who are affected by chronic pain, this reorganized classification is good news, certainly on the medical and insurance front. The ICD is effectively the number/ code that insurance companies use to determine how much they are willing to pay for services. As you all know, in the last several years it has become somewhat of an adversarial relationship between physicians, hospitals, insurance companies, and even patients in terms of getting appropriate reimbursement. This has led to increasing disparities in care.
Chronic pain is a major source of suffering; it interferes with daily functioning and often is accompanied by stress. In the past, chronic pain was linked to psychogenic or mental health disorders which are clear misclassifications. In fact, in 1986, Congress authorized an extensive review utilizing doctors, lawyers, rehabilitation specialists, and representatives from the insurance industry to review this subject. This was done because at that time, up to now, many cases were brought to court each year and decisions were made at the individual judges to determine the definition of disability and the amount of disability that this incurs for the patient. In some different venues and even among judges in the same venue, the results can vary widely. Congress recognized that this was not what they intended in setting up a pain section within the guidelines of the Social Security Administration.
The Blue Book, formally titled Disability Evaluation Under Social Security, lists impairments the Social Security Administration (SSA) considers severe enough to prevent someone from working and lays out the medical criteria for determining if that person can receive disability benefits. Disability evaluation under Social Security starts with application of the concepts in the Blue Book, including the adult and pediatric listings of all of the currently accepted impairments in medicine and surgery. This is important because the presence of your impairment in the Blue Book simplifies the process. This is true both for the adult listings and the childhood listings. The evidentiary requirements include medical evidence, which is the cornerstone of the disability determination, and it is up to the patient to obtain medical evidence showing the impairment and the severity of the impairment. As those who indeed have applied know, the Social Security Administration will try and help by obtaining hospital records which may be otherwise difficult to get, and records from different physicians who may have seen you for this condition, treated you, even briefly such as ER providers, and the like.
By law, specific medical evidence establishes that the claimant has an impairment and can show objective medical evidence based on acceptable medical science which then covers the severity of the setting and the degree of impairment. It may well be that additional consultative examinations obtained by the patient directly and suggested by Social Security in the Blue Book may be required to establish evidence related to the symptoms.
Evidence related to the symptoms can include claimants’ daily activities, the duration, frequency, and intensity of the pain symptoms, precipitating and aggravating factors, the type, dosage, and effectiveness of medications, and most importantly their side effects, treatments other than medications that have been tried for relief, and other techniques such as massage or similar non-medical approaches, and the impairment and limitation that the pain imposes on the claimant’s day-to-day existence and lifestyle.
For people with trigeminal neuralgia, lack of appropriate codes renders accurate epidemiological investigations difficult and impedes the health policy decisions regarding chronic pain and adequate financing of access to multimodality pain management. Chronic pain is defined as pain that persists or recurs for more than three months, although in the Social Security lexicon, it is required for the pain to have been present for a year and be expected to last for at least one year. Chronic pain can be the sole or leading component for example, in fibromyalgia or nonspecific low back pain. Under existing Social Security law, in order for pain to be considered in evaluating disability, there must be organic evidence of a physical or mental impairment which could reasonably be expected to produce that pain.
At the current time, prior to the instillation of the aforementioned ICD-9/11 criteria, Social Security observes four types of chronic pain. Chronic pain or an inability to cope with the pain, which is insufficiently documented, so-called chronic pain syndrome mentioned in the ICD-10 above which is not covered by current law, that too is chronic pain with competent coping but insufficient documentation of the impairment as it has to do with both work and home life, not covered by current law. Type 3 is chronic pain, inability to cope, with document impairment sufficiently covered by appointment, current law, and chronic pain competent coping documented impairment sufficient covered by current law. The Social Security Blue Book is the “bible” that chronic pain is a disabling condition but at the current time does not contain a separate listing for chronic pain syndrome and is instead linked to the specific impairments. But judges and the SSA start by looking for your claim in that publication. With the advent of the ICD-11 code, it can be hoped and it can certainly be suggested to your local political representation that Blue Book start to recognize this six subcategories structure as separate chronic pain impairments, which will significantly ameliorate some of the current difficulties in obtaining disability compensation.
At the current time, in order to be in the running, as it were, for Social Security Disability, you must have had the condition for one year and expect it to last for one year. You must have the medical evidence including imaging and documentation to support the diagnosis. You have to be able to offer information about the intensity, location, duration, and frequency of the pain, doctors who have treated your pain, and as mentioned above, medication you take to relieve the pain as well as its side effects, and other treatments and other practices, for example something as simple as applying ice or lying down. Meeting these requirements, however, will still not be enough to obtain approval for SSDI (Social Security Disability Income) and Social Security will want to review your residual function capacity to evaluate how your symptoms affect your daily activities. This is a formal evaluation, oftentimes done under the context of a physiatrist or physical therapist.
Although individual claimants can certainly file for compensation, the number and widespread extent of court cases suggests that, all too often, legal help is necessary to pursue the claim to its conclusion. Most law offices operate under the premise that you, as a client, have obtained a good deal of the information for them; then they will seek more information from the folks that you have identified as your primary physicians or others in the pain process, and then the law firm will proceed to file your claim. If necessary, the law firm will proceed to court, all of which unfortunately, comes at some expense. Your best chance for obtaining SSDI for chronic pain syndrome is to apply with multiple medical impairments at the current time or show that your disability stems from a related medical condition and is listed in the Blue Book. Oftentimes in a case that has been denied on this group of ailments, a hearing before an administrative law judge takes place with or without legal representation. That judge is attempting to use the Blue Book, and in complex cases of chronic pain syndrome it is advisable to understand that the judge will need primary evidence of one of the conditions that you claimed.
When the new coding comes into place, if we use trigeminal neuralgia for example, they could be listed under both neuropathic pain and orofacial pain, which would be an example of multiple listings, thereby giving the appropriate legal status and legal weight to an argument for compensation. As always, if there are questions or you have a filed a claim and have been denied, seeking local legal counsel may well facilitate your case.
The FPA does not endorse any product, doctor, procedure, medical institution, or its staff.
Note from Medical Editor, Jeffrey Brown MD, FACS, FAANS
The Social Security Administration also requires periodic reevaluation of your disability status every 3-7 years. It can take it away if it believes your condition no longer meets its criteria. It can reduce your benefits if you receive support from family for expenses or housing or if your income increases for any reason beyond its thresholds. There can thus be regrettable negative emotional consequences to what would should only be a positive one in your life.