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Long Island Spine Specialists, P.C.
763 Larkfield Road
2nd Floor
Commack, NY 11725
Ph: (631) 462-2225
Fax: (631) 462-2240






Child Orthopedics
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Pain Management
Spine - Cervical
Spine - General
Spine - Lumbar
Spine - Thoracic

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I'm having a tussle with my insurance company. They only pay for 12 physical therapy visits per episode of back pain. I'm on my third bout with back pain. But I maintain these are three separate problems -- not a continuation of the same problem. The insurance adjustor says it's just a recurrence of the original episode of back pain. How can I get them to see this as separate problems?

It can be difficult to tell when one episode of back pain resolves and a new episode begins. We don't have clear definitions in terms of dates, times, pain location, and so on. Studying back pain recurrence has been a bit difficult. For one thing, when is back pain a recurrence of the old problem and when is it a new and different problem? Is a second (or third) bout of back pain a recurrent episode if less than six weeks has gone by? Six months? Does the patient have to be pain free for any particular length of time (or at all) before the episode is considered a recurrence? How do we draw the line? Maybe it should be based on the patient's pain duration, location, and intensity. Maybe recurrence of back pain should only be counted as an episode if the person loses time off work or goes to see a healthcare or other back care specialist. Right now, researchers are looking for indicators that might predict back pain recurrence. There is probably more than one indicator but at least four are known to exist: 1) return of pain, 2) time off from work, 3) seeking health care services, and 4) filing a worker's compensation claim. Each of these four indicators can be either direct or indirect. For example, recurrence of pain or other symptoms is a direct indicator. Pain intensity, duration, and frequency can be individually measured and reported. In some studies, patients filled out a pain questionnaire, while others completed a daily diary. There was not a consensus as to what constituted a pain-free period in between back pain episodes. Another direct indicator of back pain recurrence was the time away from work, also referred to as repeated absences. The indirect indicators of back pain recurrence included recurrence of seeking (health) care (for back pain) and recurrence of compensation claims. Using the presence of any indicator always raises the question, Within what time frame? Some experts suggest recurrence be defined as seeking care for back pain within the first 45 days after the initial episode. Others use 45 to 90 days as a more appropriate time period to provide acceptable bounds for identifying a recurrence vs. a new episode. Since there is not complete agreement on this subject across the board, you may have to rely on your physician to help you. If he or she agrees with you that this new episode is not a continuation of the original problem, a letter of justification sent to the insurance company may help move your case along.

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