What is Complex Regional Pain Syndrome?
Complex regional pain syndrome (CRPS) is an “umbrella” term that describes prolonged, severe pain and inflammation following an injury to the arm or leg. CRPS has both acute and chronic forms—acute means the pain is recent and (so far) short-term, while chronic pain has lasted longer than six months. According to a study published in May 2023, it is estimated that over 20% of US adults (51+ million people) suffer from chronic pain and nearly 7% of US adults (17 million people) have high-impact chronic pain. Chronic pain means pain on most days or every day in the past 3 months and high-impact chronic pain refers to pain that limits life or work activities in the same timeframe.
Those with complex regional pain syndrome experience combinations of spontaneous pain that is much greater than normal following something as innocuous as a touch. CRPS does usually improve over time, but there are rare cases in which it becomes a profoundly disabling condition. While your nerve injury may be apparent, in some instances, a specialist is required to locate and treat the injury. CRPS can include:
- Unprovoked, spontaneous pain that feels like “burning,” or “pins and needles”
- “Mirror” pain that involves a matching location on the opposite, un-injured limb
- Excess or prolonged pain after the use of the limb, or even light contact with the limb
- Changes in inflammation, skin color, texture, or skin temperature in the affected limb
- Joint stiffness
- Bone wasting or excess bone growth
- Impaired movement and impaired muscle strength
What Are Other Chronic Types of Pain?
There are many types of chronic pain, including the following:
- Headaches, including debilitating migraines
- Back and neck pain
- Nerve damage pain
- Arthritis (joint pain)
- Cancer pain near a tumor
- Lasting scar tissue pain
- Fibromyalgia (all-over muscle pain)
What Are Some Common Treatments for Chronic Pain?
The specific treatment for your chronic pain will depend on the type of pain and the treatment your doctor believes will be most likely to be successful. Some of the more common pain treatments include:
- Physical therapy and other rehabilitative therapies
- Psychotherapy or counseling for secondary psychological problems tied to chronic pain
- Graded motor imagery
- Medications, including over-the-counter pain medications, prescription pain medications (nortriptyline, gabapentin, pregabalin, duloxetine, amitriptyline) topical anesthetic ointments, creams, or sprays containing lidocaine, fentanyl patches, bisphosphonates to reduce bone changes, corticosteroids, botulinum toxin injections, opioids (oxycodone, morphine, hydrocodone, fentanyl), or N-methyl-D-aspartate (NMDA) receptor antagonists like ketamine or dextromethorphan
- Spinal cord stimulation and other types of neural stimulation
- Implanted spinal-fluid drug pumps that bathe the nerve roots and spinal cord in pain-relieving medications
- Alternative and holistic therapies (chiropractic, acupuncture, biofeedback, medical marijuana)
- Sympathetic nerve block
Are Pain Treatments Covered by Insurance?
According to uspainfoundation.org, many of those with chronic pain can find the medical costs overwhelming. Chronic pain affects at least 50 million Americans—20 million of which have been diagnosed with “high-impact” pain. Many insurers may not pay for prescribed pain treatments, particularly those they consider “experimental” or “not medically necessary.”
Why Are Some Pain Treatment Claims Denied?
While some insurers will pay for chiropractic treatments, few pay for acupuncture, even though many have had good success with it. Other chronic pain treatments that are relatively new may be deemed “investigational,” therefore, not covered, including ketamine and Botox therapies. When a simple error is not the cause of the denial, the most common reasons for a pain treatment denial include:
- The treatment or drug has been deemed not medically necessary
- You inadvertently used an out-of-network provider or failed to secure prior authorization
- The treatment or drug is considered investigational or experimental
- Your plan specifically excludes the treatment or drug
- The drug is “non-formulary,” meaning the insurer believes there is a less-expensive, equally effective drug
- Your therapy deviated from your plan’s treatment requirements
Of course, any of these reasons could be cloaking the real reason your insurance company denied your pain treatment claim—it is expensive, and it simply doesn’t want to pay for it.
What Should You Do if You Receive a Pain Treatment Insurance Denial?
Any insurer may deny pain treatments and may do so for a variety of reasons. Anthem Blue Cross, Blue Shield, Health Net, Kaiser, UnitedHealthcare, Aetna, and other insurers may issue a pain treatment insurance denial. If this occurs, it is important to know you have options. Your physician may resubmit the claim, along with a letter of explanation as to why the specific pain treatment is necessary. If this is unsuccessful, your insurance plan should outline the steps required for an appeal.
The insurer must provide you (in writing) the specific reason for the denial and detailed instructions on appeal steps along with deadlines to submit your appeal. There are multiple levels of appeal, meaning that even if your first appeal is denied, you have additional levels of appeal. When you are in pain and struggling to make it through each day, the appeal process can feel overwhelming. This is where the Law Offices of Scott Glovsky can step in and handle the appeal process on your behalf.
How Attorney Scott Glovsky Can Help with Your Pain Treatment Insurance Denial
If you’ve received a Complex Regional Pain Syndrome insurance denial or any pain treatment insurance denial, attorney Scott Glovsky can help. It is both insulting and discouraging to find that after faithfully paying your insurance premiums for years, your insurer is denying a necessary treatment or drug. While you are understandably overwhelmed, don’t give up!
All you need is one person who cares enough to fight for your rights and your future. That person is attorney Scott Glovsky. The hard-fought victories of the Law Offices of Scott Glovsky have impacted millions of policyholders by forcing insurance companies to change their behavior. This includes the process of reviewing requests for medically necessary treatments. Let us help you through this difficult time—contact the Law Offices of Scott Glovsky today.