Care management requirements change for members with low back pain effective March 1

Effective March 1, 2016, the following two changes go into effect for members with low back pain:

• These members are no longer required to see a physical medicine and rehabilitation provider for evaluation prior to referral to a neurosurgeon or orthopedic surgeon. The requirement for a referral to a physical medicine and rehabilitation provider had been part of BCN's Spine Care Referral Program.


• Clinical review is no longer required for the initial visit to a neurosurgeon or orthopedic surgeon and for office visits and procedures. These visits may require a referral from the member's primary care physician, depending on the region.

These changes apply to BCN HMO^SM (commercial) and BCN Advantage^SM members who have a low back pain condition defined by the select ICD-10 diagnosis codes that were previously subject to these requirements as part of BCN's Spine Care Referral Program.

The Spine Care Referral Program page on this website will reflect this information by March 1.

For additional information on BCN's referral requirements, which vary by region, refer to the BCN Referral / Clinical Review Program, available on the Clinical Review & Criteria Charts page on this website. Information on requirements for clinical review is also available in that document.

Posted: February 2016
Line of business: Blue Care Network