Utilization Review Checklist
Chronic Pain Programmes — Functional Restoration, Work Conditioning and Psychological Treatment
Derived from the ACOEM Chronic Pain Guideline, edition 22 December 2025, as adopted into the California MTUS 1 June 2026. CPT 97545, 97546, 97799, 96156, 96164, 90834. ICD-10 G89.29, G89.4, M54.5, M25.50, F45.42.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
Procedures — the guideline treats each separately
Tertiary pain programme — interdisciplinary pain rehabilitation, multidisciplinary rehabilitation, chronic pain management or functional restoration
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low
Indications
Any one of the following
Tertiary pain programme — interdisciplinary pain rehabilitation, multidisciplinary rehabilitation, chronic pain management or functional restoration
“Tertiary pain programs are selectively recommended for a minority of patients with chronic pain who have failed trials of evidence-based conventional treatments, lack other evidence-based treatment options, and remain significantly incapacitated.” — p. 414
Required:
Failed trials of evidence-based conventional treatments, lacking other evidence-based options, and remaining significantly incapacitated
“Tertiary pain programs are selectively recommended for a minority of patients with chronic pain who have failed trials of evidence-based conventional treatments, lack other evidence-based treatment options, and remain significantly incapacitated.” — p. 414
Dose, Duration and Discontinuation
All of the following
A minimum of 5 hours a day, 5 days a week, over 4 to 6 weeks, to a maximum of 160 hours — at least 160
“Tertiary pain program treatment is generally a minimum of 5 hours/day, 5 days/week; 4-6 weeks; 160 hours maximum.” — p. 415
AND
Discontinued on programme completion, non-compliance, or lack of progress, with objective measures reviewed at intervals no longer than 2 weeks
“At any point where there is a plateau and/or lack of improvement in objective measures over not longer than 2-week intervals, the program should be discontinued.” — p. 415
Labelled 'Sometimes Recommended' and described as selectively recommended for a MINORITY of patients. The guideline requires both programme-specific and patient-specific criteria to be met before referral. It also sets a hard shape for the programme: a minimum of 5 hours a day, 5 days a week, over 4 to 6 weeks, to a maximum of 160 hours, with any exception negotiated with the payer.
Work conditioning or work hardening programme
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
Indications
Any one of the following
Work conditioning or work hardening programme
“remain completely off work or are on modified duty for 6 to 12 weeks, whose job has moderate to high job physical demands” — p. 410
Required:
Completely off work or on modified duty for 6 to 12 weeks, in a job with moderate to high physical demands — at least 6 weeks
“remain completely off work or are on modified duty for 6 to 12 weeks, whose job has moderate to high job physical demands” — p. 410
Prior Treatment
All of the following
Not responded to a 4- to 6-week therapy programme, or a graded therapy programme of at least 6 to 8 weeks including aerobic and strengthening exercise — at least 4 weeks
“have not responded to less costly interventions including a 4- to 6-week physical (or occupational) therapy program or a graded therapy program of at least 6 to 8 weeks that includes aerobic and strengthening exercise components” — p. 410
AND
A stated strong interest and expectation to return to work, with employer cooperation and a careful assessment of occupational demands
“have a stated strong interest and expectation to return to work” — p. 410
The step BEFORE a tertiary programme. Its indications require the patient to have been off work or on modified duty for 6 to 12 weeks in a job with moderate to high physical demands, and to have failed a 4- to 6-week therapy programme or a graded programme of at least 6 to 8 weeks with aerobic and strengthening components. A tertiary referral that skipped this step will be asked why.
Psychological evaluation with psychometric testing
Recommended. A psychological evaluation with psychometric testing is recommended as part of the evaluation and management of patients with chronic pain who are not at full work status.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high · p. 428
Indications — required:
Chronic pain with the patient not at full work status
“A psychological evaluation with psychometric testing is recommended as part of the evaluation and management of patients with chronic pain who are not at full work status.” — p. 428
Recommended at High confidence for patients with chronic pain who are NOT at full work status. Also a prerequisite elsewhere in the MTUS: the Low Back chapter's spinal cord stimulator criteria require an independent psychological evaluation by a practitioner not employed by the requesting physician.
Cognitive behavioural therapy for subacute or chronic pain
Moderately Recommended. CBT is indicated for all patients with chronic pain conditions.
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence high · p. 433
Indications — required:
Subacute or chronic pain — CBT is indicated for all patients with chronic pain conditions
“CBT is indicated for all patients with chronic pain conditions.” — p. 433
The strongest positive finding in this cluster — Moderately Recommended on Evidence (B) at High confidence — and the guideline states CBT is indicated for ALL patients with chronic pain conditions. A request for it should be among the easiest to support in this whole set.