BASIC (04-00)

A. Definitions

1. Pain Specialist

1. A pain specialist may be an orthopedist, a neurologist, a neurosurgeon, a physiatrist, a psychiatrist, etc., but is different from others in these fields because of:

   • Special training in pain.

   • Special experience in clinical management of pain.

   • Recognition within the specialty as an expert in pain and pain management.

2. There is currently no specialty board for pain and no certification program for training of pain personnel.

2. Pain Center (Clinic)

A pain center is a specialized facility devoted to the evaluation, treatment, and/or rehabilitation of pain patients.

1. Services offered:

   • Indepth study and treatment of one particular aspect of pain.

   • Specialized treatment, e.g., nerve block, bio feedback.

   • Comprehensive evaluation of the physical, emotional and sociological aspects of chronic pain problems with facilities for pain management. Such an evaluation would usually include medical, psychological, functional and vocational assessments.

2. Availability — Approximately 1000-1500 in the United States but not in all areas.

3. Certification for pain management facilities — Done by an organization which sets national standards.

B. Policy

1. Evidence Of Record

In evaluating pain, give consideration to:

1. All available medical evidence,

2. Statement(s) of:

   • The claimant,

   • Treating or examining physicians, and

   • Others.

2. CE

Evidence from CEs, when applicable.

C. Procedure - General

1. Pain Reasonably Consistent With Underlying Documented Impairment

1. Do not obtain specialized CE by pain specialist or pain center (clinic).

2. Evaluate in accordance with DI 24501.021.

2. Pain Not Reasonably Consistent With Underlying Documented Impairment

1. Do not obtain pain CE if any of the following apply:

   • Fully favorable decision can be made on the basis of the documented impairment.

   • Necessary information about pain (see DI 24501.021) can be obtained from medical sources of record, the claimant, and others. (See DI 22510.011B.l.)

2. Obtain a pain CE only when all of the following are present:

   • A fully favorable decision is not possible.

   • Assessment of the existence and extent of any limitations due to pain is essential to make a determination.

   • The necessary evidence (see DI 24501.021) is not otherwise available from medical sources of record, the claimant, and others.

3. Selecting Pain CE Source

Make the decision as to the proper source for purchase of a pain CE in the following order.

1. Treating Source (see DI 22510.010B.1.)

2. Pain Specialist (when and if available)

   May already be on CE panel, e.g., neurologist, orthopedist, but also has special training and experience in pain and pain management.

   •     OR

   Pain Center (Clinic) (when and if available)

   • Centers which provide a multidisciplinary approach and a comprehensive report to include medical, psychological, functional and vocational assessments in a reasonable time are preferred.

   • Should be able to provide quantitative measurements of dysfunction and assessment of vocational capabilities and outlook.

3. CE Panelist (not a pain specialist)

   • Are available in all geographic areas.

   • Can provide needed information about pain when asked direct, specific questions.

D. Procedure - List Codes

1. List Code Numbers

List code numbers have been established for certain cases involving pain. Enter in item 26 of the SSA-831-U3 or item 34 of the SSA 832-U3 and SSA-833-U3. (See DI 33530.005 for the index of disability-related list codes.)

2. Code 251

Use when limitation due to pain further restricts residual functional capacity (RFC) but the claimant still retains the capacity to do SGA.

NOTE: Only applies to medical/vocational decisions of denial or cessation.

3. Code 252

Use when limitations due to pain further restrict RFC to the extent that the claimant would be unable to perform SGA.

NOTE: Only applies to medical/vocational decisions of allowance or continuance.