Too Complex to Treat? Equity in Access to Inpatient Pediatric Pain Rehabilitation

An adolescent with complex regional pain syndrome, functional neurological symptoms, and significant psychosocial complexity was hospitalized for severe decline. Despite meaningful progress through a structured, multidisciplinary inpatient approach, she was repeatedly denied admission to pediatric inpatient pain rehabilitation programs across the United States-often based on process requirements such as caregiver engagement, outpatient intake completion, and medical or psychiatric complexity. These denials delayed access to intensive, coordinated care previously shown to benefit her. This case illustrates how the intersection of medical and psychosocial complexity can operate as an unspoken exclusion criterion in pediatric pain rehabilitation, disproportionately affecting vulnerable youth. Policies and eligibility checklists intended to optimize outcomes may inadvertently reinforce inequities when applied without attention to context. We argue that readiness should not be defined solely by patient or family characteristics but by the health system's capacity to respond to complexity with flexibility and equity. We propose system-level strategies to promote equitable access: requiring clinician-to-clinician dialogue before denials are issued, creating formal appeal pathways to reconsider complex cases, clarifying and publishing admission criteria, and designing inclusive rehabilitation tracks. Rather than asking whether patients are ready for our programs, we must ask whether our programs are prepared to meet our patients.