Medical Policy



Subject: Implantable Infusion Pumps
Document #: SURG.00068 Current Effective Date:    06/28/2017
Status: Revised Last Review Date:    05/04/2017

Description/Scope

This document addresses the use of implantable infusion pumps, intended to provide long-term, continuous or intermittent drug infusion. The document does not address implantable reservoirs or implantable infusion systems without a pump.

Position Statement

Medically Necessary:

Implantable infusion pumps are considered medically necessary when used to deliver drugs for the treatment of:

  1. Primary liver cancer (intrahepatic artery injection of chemotherapeutic agents); or
  2. Metastatic colorectal cancer where metastases are limited to the liver (intrahepatic artery injection of chemotherapeutic agents); or
  3. Severe, refractory spasticity of cerebral or spinal cord origin in individuals who are unresponsive to or cannot tolerate oral baclofen (Lioresal® ) therapy (intrathecal injection of baclofen).

Permanently implanted intrathecal (intraspinal) infusion pumps for the administration of opiates or non-opiate analgesics, in the treatment of chronic intractable pain, are considered medically necessary when:

  1. Used for the treatment of malignant pain (for example, pain associated with cancer) and all of the following criteria are met:
    1. Strong opioids or other analgesics in adequate doses, with fixed schedule (not PRN) dosing, have failed to relieve pain or intolerable side effects to systemic opioids or other analgesics have developed; and
    2. Life expectancy is greater than 3 months (less invasive techniques such as external infusion pumps provide comparable pain relief in the short term and are consistent with standard of care); and
    3. Tumor encroachment on the thecal sac has been ruled out by appropriate testing; and
    4. No contraindications to implantation exist such as sepsis or coagulopathy; and
    5. A temporary trial of spinal (epidural or intrathecal) opiates or non-opiate analgesics has been successful as defined by a 50% reduction in pain, prior to permanent implantation.
      Note: A temporary trial of intrathecal (intraspinal) infusion pumps used for the treatment of malignant pain is considered medically necessary only when criteria 1-4 above are met.
  2. Used for the treatment of non-malignant pain (for example, pain not associated with cancer) with a duration of greater than 6 months and all of the following criteria are met:
    1. Documentation, in the medical record, of the failure of 6 months of other conservative treatment modalities (pharmacologic, surgical, psychologic or physical), if appropriate and not contraindicated; and
    2. Intractable pain secondary to a disease state with objective documentation of pathology in the medical record; and
    3. Further surgical intervention is not indicated; and
    4. Psychological evaluation has been obtained and evaluation unequivocally states that the pain is not psychologic in origin and that benefit would occur with implantation; and
    5. No contraindications to implantation exist such as sepsis or coagulopathy; and
    6. A temporary trial of spinal (epidural or intrathecal) opiates or non-opiate analgesics has been successful prior to permanent implantation as defined by a 50% reduction in pain and documentation in the medical record of improved function.
      Note: A temporary trial of intrathecal (intraspinal) infusion pumps used for the treatment of non-malignant pain is considered medically necessary only when criteria 1-5 above are met.

Note: When an implantable/intrathecal infusion pump is determined to be medically necessary, the supplies necessary for the proper use of the pump are considered medically necessary.  

Replacement of an implantable/intrathecal infusion pump (which may also involve upgrading to the most current technology) is considered medically necessary when the device is not functioning or when a built-in system in the pump provides notification of an impending failure.

Not Medically Necessary:

Replacement or upgrades of an implantable/intrathecal infusion pump is considered not medically necessary when requested for convenience or to upgrade to newer technology when the current components remain functional.

Investigational and Not Medically Necessary:

Implantable infusion pumps are considered investigational and not medically necessary for the infusion of heparins for thromboembolic disease or antibiotics for osteomyelitis.

All other uses of implantable infusion pumps, including fully implantable insulin pumps, are considered investigational and not medically necessary.

Rationale

The role of opioid therapy in treatment of pain is well established in the medical literature. Individuals who have proven unresponsive to less invasive medical therapy and who require large doses of opioids may be candidates for an implantable delivery system that permits intrathecal administration. This system delivers the opioid directly to the receptors in the spinal cord, allowing smaller doses to be used and thereby minimizing side effects. A preliminary trial of an intraspinal opioid drug is administered using a temporary intrathecal/epidural catheter (continuous infusion or bolus injection) to substantiate adequate pain relief and acceptable degree of side effects. This position is supported by multiple case control studies.

The use of continuous chemotherapy infusion treatment has been studied for individuals with primary hepatic cancer and metastatic colorectal cancer to the liver. This method of chemotherapy infusion has been found to improve medical outcomes in select individuals where continuous chemotherapy is believed to be appropriate. The evidence supporting this conclusion includes multiple randomized controlled trials. Prospective randomized trials of individuals with unresectable liver disease have shown that compared to conventional systemic therapy, hepatic artery infusion is associated with an increased tumor response rate.

Several studies have evaluated interventions that combine radiotherapy and concomitant intra-arterial cisplatin, otherwise known as RADPLAT for treatment of head and neck cancer. Ackerstaff and colleagues (2009) reported results from a randomized multicenter study that examined 17 quality-of-life scale assessments after treatment with radiotherapy with intravenous or intra-arterial cisplatin. A total of 207 participants with advanced head and neck cancer were included in the study. Quality-of-life symptoms reported between both groups were similar; the only statistically significant difference reported between groups was the nausea/vomiting scale at 7 weeks, at which time the rate of symptoms was higher in the intravenous compared to the intra-arterial population. Current evidence has not demonstrated a clear advantage of intra-arterial chemotherapy delivery via an intra-arterial catheter compared to intravenous chemotherapy in combination with radiotherapy for individuals with advanced head and neck cancer (Rasch, 2010). Ongoing clinical trials are underway to explore the use of intra-arterial chemotherapy in locally advanced squamous cell carcinoma.

Implantable pumps for delivery of medication to the intrathecal space have been developed as an alternative to chronic systemic administration for the treatment of spasticity of cerebral or spinal origin. These pumps have been demonstrated in numerous randomized controlled trials to reduce adverse effects such as tolerance, dependency, and neurotoxicity.

The use of implantable pumps for infusion of antithrombotic medications for thromboembolic disease, or for the infusion of antibiotics for osteomyelitis, has not been demonstrated to provide any additional improvement in net health outcomes above standard care with bolus or subcutaneous drug administrations. This therapy does not prevent the occurrence of complications or morbidity nor does it significantly relieve pain over other less invasive treatment methods. The risks involved in the implantation and maintenance of implantable infusion pumps for these conditions is not outweighed by any potential benefits. The evidence supporting this conclusion includes multiple case series studies.

Fully implantable insulin pumps are designed to deliver insulin via intraperitoneal or intravenous routes in a programmed and controlled manner to diabetics. However, these pumps have been associated with a high incidence of device malfunction related to catheter obstruction, among other malfunctions. Newer devices are under development that are expected to drastically reduce the problem of catheter obstruction. With additional refinements underway, implantable insulin pumps may eventually prove beneficial in the treatment of insulin dependent diabetics. To show benefit, however, additional long-term randomized prospective studies are needed.

Background/Overview

Implantable Infusion Pumps

Implantable infusion pump use for the delivery of intrathecal (intraspinal) opiates is based on the existence of opioid (narcotic) receptors on the spinal cord to achieve "selective spinal analgesia" (pain relief). Pumps provide for the long-term delivery of opioid (narcotic) medication in the management of malignant (cancer) pain and nonmalignant (non-cancer) pain. Examples of appropriate nonmalignant pain syndromes which may be treated with implantable pumps include "failed back surgery", chronic arachnoiditis, visceral pain syndromes, post herpetic neuralgia, phantom limb pain, spinal cord injuries, peripheral neuropathies and reflex sympathetic dystrophy. A successful temporary trial of spinal opiates is required both to evaluate analgesic responsiveness and to increase the long-term success of the procedure. Individuals must be closely monitored as conversion from high dose oral or systemic opioids to spinally administered opioids will sometimes result in withdrawal symptoms.

Treatment with this therapy should remain a last resort, used only after all other appropriate therapies have failed. A permanently implantable drug-infusion system is not usually appropriate when life expectancy is 3 months or less; for such individuals, external drug infusion systems can appropriately provide spinal analgesia and comparable pain relief.

The implantable infusion pump (IIP) is a drug delivery system that provides continuous infusion of an agent at a constant and precise rate. The purpose of an IIP is to deliver therapeutic levels of a drug directly to a target organ or compartment. It is frequently used to deliver chemotherapy directly to the hepatic artery or superior vena cava.

An IIP is surgically placed in a subcutaneous pocket under the infraclavicular fossa or in the abdominal wall and a catheter is threaded into the desired position. A drug is infused over an extended period of time. The drug reservoir may be refilled as needed by an external needle injection through a self-sealing septum in the IIP. Bacteriostatic water or physiological saline is often used to dilute therapeutic drugs. A heparinized saline solution may also be used during an interruption of drug therapy to maintain catheter patency.

There is a range of totally implanted catheters with implanted reservoirs and manual pumps as well as totally implanted catheters with implanted infusion pumps. Implantable infusion pumps are available in either programmable or non-programmable models, depending on the type of medication delivery required. Programmable pumps are for flexible medication delivery as dose titration and regulation will vary due to the dynamic nature of the individual. Programmable designs facilitate flexible dosing options and precise dose titration over time.

An example of a flexible medication delivery pump is the SynchroMed® electronic pump, manufactured by Medtronic Inc. (Minneapolis, MN, USA). This pump contains a collapsible reservoir that can be filled with 10 to 18 ml of liquid medication and a peristaltic pump that pushes the medication through a bacteriostatic filter and catheter into the spinal canal. The SyncroMed II Infusion system (implanted after July 2004) is indicated to deliver prescribed medication for the treatment of chronic pain, severe chronic pain and severe spasticity, respectively. The infusion system has a battery life of 5-7 years with a maximum shut-down design to ensure that the pump provides proper administration of intrathecal therapy. The pump has a built in elective replacement indicator (ERI), this alarm sounds when the pump is nearing the end of service (EOS). The pump will no longer operate 90 days after the alarm has sounded, a pump replacement is recommended to avoid interruption in service and risk of withdrawal of baclofen. The U. S. Food and Drug Administration (FDA) issued a Class I recall in September 2011 due to the potential for reduction of battery performance in the SyncroMed II pump. Codman & Shurtleff, Inc. (Raynham, MA), manufacturer of Medstream™ Programmable Infusion System received FDA premarket supplement for the implantable infusion pump and catheter system for use with baclofen in the treatment of severe spasticity.

Non-programmable pumps are for fixed rate medication delivery when the dosage is expected to be stable. Possible routes of administration include intravenous, intrahepatic, intra-arterial, subcutaneous, intraperitoneal, intrathecal, epidural, and intraventricular.

Fully Implantable Insulin Pumps

At the time of this writing, no implantable insulin pumps have received FDA approval for marketing. The MiniMed® 2000 and MiniMed® 2001 implantable insulin pumps have been granted investigational status and are currently being evaluated in clinical trials.

Intrathecal Infusion Pumps

The intrathecal (IT) catheter is inserted through a needle into the intraspinal space, usually at the lumbar or thoracic level. The other end of the catheter is connected to the pump and then filled with medication. The choice of IT pump depends on the indications for intraspinal therapy, the need for bolus versus continuous infusion, the available support services, cost to the individual, and the individual's general medical condition, ambulatory status and life expectancy.

External programming is used to set the dosage, rate and timing via telemetry to the pump. The pump needs to be refilled every 4 to 8 weeks by percutaneous injection, depending on flow rate, and trained medical, nursing or technical staff must perform the refilling process.

Definitions

Bacteriostatic: An agent that inhibits the growth or multiplication of bacteria.

Bolus: A large dose of a drug given intravenously for the purpose of rapidly achieving the needed therapeutic concentration in the bloodstream.

Hepatic colorectal metastases: Colorectal cancer that has spread from its site of origin to the liver.

Infraclavicular fossa: A triangular depression bounded by the clavicle and the adjacent borders of the deltoid and pectoralis major muscles.

Intrathecal space: The space between the spinal cord and the surrounding membrane (dura mater), which is filled with cerebrospinal fluid.

Osteomyelitis: Inflammation of the bone due to infection.

Parenteral: Is a route of administration by injection as in subcutaneous, intramuscular, or intravenous.

Primary liver cancer: A cancer that originates within liver cells, as opposed to having spread from other organs.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT  
36260 Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver)
36261 Revision of implanted intra-arterial infusion pump [when specified as replacement]
36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump
36583 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same venous access
61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter [when specified as an implantable pump]
62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy
62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy
62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir [when used with an implantable pump]
62361 Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump
62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming
   
HCPCS  
C1772 Infusion pump, programmable (implantable)
C1891 Infusion pump, nonprogrammable, permanent (implantable)
C2626 Infusion pump, nonprogrammable, temporary (implantable)
E0782 Infusion pump, implantable, non-programmable (includes all components, e.g., pump, catheter, connectors, etc.
E0783 Infusion pump, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)
   
ICD-10 Procedure  
0JH60VZ- 0JH63VZ Insertion of infusion pump into chest subcutaneous tissue and fascia [by approach; includes codes 0JH60VZ, 0JH63VZ]
0JH70VZ-0JH73VZ Insertion of infusion pump into back subcutaneous tissue and fascia [by approach; includes codes 0JH70VZ, 0JH73VZ]
0JH80VZ-0JH83VZ Insertion of infusion pump into abdomen subcutaneous tissue and fascia [by approach; includes codes 0JH80VZ, 0JH83VZ]
0JHT0VZ-0JHT3VZ Insertion of infusion pump into trunk subcutaneous tissue and fascia [by approach; includes codes 0JHT0VZ, 0JHT3VZ]
   
ICD-10 Diagnosis  
  All diagnoses not listed below as investigational and not medically necessary

When services are Not Medically Necessary:
For the procedure codes listed above for replacement of a pump, when indicated in the Position Statement section as not medically necessary.

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above for the following diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

ICD-10 Diagnosis  
E08.00-E08.9 Diabetes mellitus due to underlying conditions
E09.00-E09.9 Drug or chemical induced diabetes mellitus
E10.10-E10.9 Type 1 diabetes mellitus
E11.00-E11.9 Type 2 diabetes mellitus
E13.00-E13.9 Other specified diabetes mellitus
H05.021-H05.029 Osteomyelitis of orbit
I74.0-I74.9 Arterial embolism and thrombosis
M27.2 Inflammatory conditions of jaws (osteomyelitis)
M46.20-M46.28 Osteomyelitis of vertebra
M86.00-M86.69 Osteomyelitis
M86.8X0-M86.8X9 Other osteomyelitis
M86.9 Osteomyelitis, unspecified
O24.011-O24.93 Diabetes mellitus in pregnancy, childbirth, and the puerperium
   
References

Peer Reviewed Publications:

  1. Ackerstaff AH, Balm AJ, Rasch CR, et al. First-year quality of life assessment of an intra-arterial (RADPLAT) versus intravenous chemoradiation phase III trial. Head Neck. 2009; 31(1):77-84.
  2. Albright AL, Gilmartin R, Swift D, et al. Long-term intrathecal baclofen therapy for severe spasticity of cerebral origin. J Neurosurg. 2003; 98(2):291-295.
  3. Albright AL. Intrathecal baclofen in cerebral palsy movement disorders. J Child Neurol. 1996; 11(Suppl 1):S29-S35.
  4. Anderson V, Burchiel KJ. A prospective study of long-term intrathecal morphine in the management of chronic nonmalignant pain. Neurosurgery. 1999; 44(2):289-300.
  5. Awaad Y, Tayem H, Munoz S, et al. Functional assessment following intrathecal baclofen therapy in children with spastic cerebral palsy. J Child Neurol. 2003; 18(1):26-34.
  6. Bloomgarden ZT. Treatment issues in type 1 diabetes. Diabetes Care. 2002; 25(1):230-236.
  7. Carek PJ, Dickerson LM, Sack JL. Diagnosis and management of osteomyelitis. Am Fam Phys. 2001; 63(12):2413-2420.
  8. Damascelli B, Patelli G, Frigerio LF, et al. First clinical experience with a high-capacity implantable infusion pump for continuous intravenous chemotherapy. Cardiovasc Intervent Radiol. 1999; 22(1):37-43.
  9. Gilmer-Hill HS, Boggan JE, Smith KA, Wagner FC Jr. Intrathecal morphine delivered via subcutaneous pump for intractable cancer pain: a review of the literature. Surg Neurol. 1999; 51(1):12-15.
  10. Gooch JL, Oberg WA, Grams B, et al. Care provider assessment of intrathecal baclofen in children. Dev Med Child Neurol. 2004; 46(8):548-552.
  11. Hartkamp A, Van Boxtel AD, Zonnenberg BA, Witteveen PO. Totally implantable venous access devices: evaluation of complications and a prospective comparative study of two different port systems. Neth J Med. 2000; 57(6):215-223.
  12. Hoebers FJ, Pluim D, Verheij M, et al. Prediction of treatment outcomes by cisplatin-DNA adduct formation in patients with stage III/IV head and neck squamous cell carcinoma, treated by concurrent cisplatin-radiation (RADPLAT). Int J Cancer. 2006; 119:750-756.
  13. Jeandidier N, Boullu S, Busch-Brafin MS, et al. Comparison of antigenicity of Hoechst 21PH insulin using either implantable intraperitoneal pump or subcutaneous external pump infusion in type 1 diabetic patients. Diabetes Care. 2002; 25(1):84-88.
  14. Kemeny N, Huang Y, Cohen AM, et al. Hepatic arterial infusion of chemotherapy after resection of hepatic metastases from colorectal cancer. NEJM. 1999:341(27):2039-2048.
  15. Kessler L, Tritschler S, Bohbot A, et al. Macrophage activation in type 1 diabetic patients with catheter obstruction during peritoneal insulin delivery with an implantable pump. Diabetes Care. 2001; 24(2):302-307.
  16. Krach LE, Kriel RL, Gilmartin RC, et al. Hip status in cerebral palsy after one year of continuous intrathecal baclofen infusion. Pediatr Neurol. 2004; 30(3):163-168.
  17. Metz L. Multiple sclerosis: symptomatic therapies. Semin Neurol. 1998; 18(3):389-395.
  18. Penn RD, Paice JA. Chronic intrathecal morphine for intractable pain. J Neurosurg 1987; 67:182-186.
  19. Pohl M, Rockstroh G, Ruckriem S, et al. Time course of the effect of a bolus dose of intrathecal baclofen on severe cerebral spasticity. J Neurol. 2003; 250(10):1195-1200.
  20. Prager J, Jacobs M. Evaluation of patients for implantable pain modalities: medical and behavioral assessment. Clin J Pain. 2001; 17(3):206-214.
  21. Rasch CR, Hauptmann M, Schornagel J, et al. Intra-arterial versus intravenous chemoradiation for advanced head and neck cancer: Results of a randomized phase 3 trial. Cancer. 2010; 116(9):2159-2165.
  22. Sadahiro S, Suzuki T, Ishikawa K, et al. Prophylactic hepatic arterial infusion chemotherapy for the prevention of liver metastasis in patients with colon carcinoma: a randomized control trial. Cancer. 2004:100(3):590-597.
  23. Saudek CD, Duckworth WC, Giobbie-Hurder A, et al. Implantable insulin pumps vs. multiple dose insulin for non-insulin-dependent diabetes mellitus: a randomized clinical trial. Dept of Veterans Affairs Implantable Insulin Pump Study Group. JAMA. 1996; 276(16):1322-1327.
  24. Skitzki JJ, Chang AE. Hepatic artery chemotherapy for colorectal liver metastases: technical considerations and review of clinical trials. Surg Oncol. 2002; 11(3):123-135.
  25. Smith TJ, Staats PS, Deer T, et al. Implantable Drug Delivery Systems Study Group. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002; 20(19):4040-4049.
  26. Taricco M, Adone R, Pagliacci C, Telaro E. Pharmacological interventions for spasticity following spinal cord injury. Cochrane Database Syst Rev. 2000; (2):CD001131.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Anesthesiologists, Inc. Practice guidelines for chronic pain management: An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010; 112(4):810-833.
  2. Australian Safety and Efficacy Register of New Interventional Procedures; Surgical Implantable Spinal Infusion Devices for Chronic Pain and Spasticity. 2003; 1-46.
  3. Centers for Medicare and Medicaid Services. National Coverage Determination for Infusion Pumps. NCD #280.14. Effective December 17, 2004. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=223&ncdver=2&SearchType=Advanced&CoverageSelection=National&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&KeyWord=infusion&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAAAA%3d%3d&. Accessed on March 7, 2017.
  4. NCCN Clinical Practice Guideline in Oncology™ (NCCN). © 2013 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on February 27, 2017.
    • Colon Cancer (V.1.2017). Revised November 23, 2016.
    • Hepatobiliary Cancer (V.2.2016). Revised June 23, 2016.
Websites for Additional Information
  1. National Cancer Institute (NCI). Available at: http://www.cancer.gov/types. Accessed on March 6, 2017.
    • Adult primary liver cancer treatment (PDQ® ). Revised January 31, 2017.
    • Colon cancer treatment (PDQ). Revised February 27, 2017.
    • Metastatic squamous cell cancer with occult primary treatment (PDQ). Revised September 25, 2015.
Index

Drug Infusion Pumps
HAI
Hepatic Arterial Infusion
Implantable Infusion Pumps
Intrathecal Baclofen for Spasticity
Venous Access Device, Implantable

Document History
Status Date Action
Revised 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised 05/03/2017 Hematology/Oncology Subcommittee review. Updated formatting in Position Statement and added 'or' to the indications under 'Implantable infusion pumps'. Updated Background, References and Websites sections.
Revised 05/05/2016 MPTAC review.
Revised 05/04/2016 Hematology/Oncology Subcommittee review. Corrected grammatical error in MN section. Updated Description/Scope, Rationale, References and Websites sections. Removed ICD-9 codes from Coding section
Reviewed 05/07/2015 MPTAC review.
Reviewed 05/06/2015 Hematology/Oncology Subcommittee review. Reformatted medically necessary section. Updated Description, Rationale, References and Websites sections.
Revised 05/15/2014 MPTAC review. Clarified medically necessary statement for replacement implantable/intrathecal infusion pump. Updated Websites.
Revised 11/14/2013 MPTAC review.
Revised 11/13/2013 Hematology/Oncology Subcommittee review. Removed head and neck cancer as a medically necessary indication for implantable infusion pumps when used to deliver drugs. Updated Rationale, Background, References and Websites. 
Reviewed 11/08/2012 MPTAC review.
Reviewed 11/07/2012 Hematology/Oncology Subcommittee review. Background, References and Websites updated.
Revised 11/17/2011 MPTAC review.
Revised 11/16/2011 Hematology/Oncology Subcommittee review. Added medically necessary and not medically necessary statement to address coverage of replacement or upgrades of implantable/intrathecal infusion pump. Background, Coding, and Websites updated.
Reviewed 11/18/2010 MPTAC review.
Reviewed 11/17/2010 Hematology/Oncology Subcommittee review. Definitions, Websites and References updated.
Reviewed 08/19/2010 MPTAC review. Websites and References updated.
Reviewed 08/27/2009 MPTAC review. References updated.
Reviewed 08/28/2008 MPTAC review. References updated. Updated Coding section with 10/01/2008 ICD-9 changes.
  02/21/2008 The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 08/23/2007 MPTAC review. References and coding updated.
Revised 09/14/2006 MPTAC review. Removed place of service and length of stay information. Clarified language for temporary trials of pumps.
Reviewed 06/08/2006 MPTAC review. References updated.
Revised 03/23/2006 MPTAC review. Added "non-opiate analgesics" as medically necessary for use during a temporary trial of an intrathecal infusion pump. Added length of stay information.
 

11/18/2005

 

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Reviewed 07/14/2005 MPTAC review. Document number changed from DME.00026 to SURG.00068.
Reviewed

04/28/2005

 

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title
Anthem, Inc.

04/27/2004

DME.00007

Implantable Infusion Pumps (excluding chronic pain)
 

07/27/2004

SURG.00060

Implanted Infusion Pumps for Treatment of Pain and Implanted Spinal Cord Stimulators
 

 

 

 
WellPoint Health Networks, Inc

06/24/2004

2.06.20

Hepatic Artery Infusion
 

09/23/2004

3.01.07

Implantable Infusion Pumps
 

09/23/2004

8.10.01

Intrathecal Baclofen for Spasticity