Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Anesthetic infusion pumps have not been proven to be safe and effective, are considered experimental, and are not covered.

1. Infusion pumps for intralesional administration of narcotic analgesics and anesthetics are considered experimental and investigational because the effectiveness of these pumps has not been demonstrated in well-designed clinical studies in the peer-reviewed published medical literature.
2. Infusion pumps for intraarticular administration of narcotic analgesics and anesthetics are considered experimental and investigational because they have not been proven to improve post-operative pain control.

Codes Used In This BI:

E0781                        AMB INFUS PUMP 1/MX CHANNL W/ADMIN

1. Kushner DM, LaGalbo R, Connor JP, et al. Use of a bupivacaine continuous wound infusion system in gynecologic oncology: A randomized trial. Obstet Gynecol. 2005;106(2):227-233.
2. Baig MK, Zmora O, Derdemezi J, et al. Use of the ON-Q pain management system is associated with decreased postoperative analgesic requirement: Double blind randomized placebo pilot study. J Am Coll Surg. 2006;202(2):297-305.
3. Parker RD, Streem K, Schmitz L, Martineau PA; Marguerite Group. Efficacy of continuous intra-articular bupivacaine infusion for postoperative analgesia after anterior cruciate ligament reconstruction: A double-blinded, placebo-controlled, prospective, and randomized study. Am J Sports Med. 2007;35(4):531-536.
4. Webb D, Guttmann D, Cawley P, Lubowitz JH. Continuous infusion of a local anesthetic versus interscalene block for postoperative pain control after arthroscopic shoulder surgery. Arthroscopy. 2007;23(9):1006-1011.
5. Polglase AL, McMurrick PJ, Simpson PJ, et al. Continuous wound infusion of local anesthetic for the control of pain after elective abdominal colorectal surgery. Dis Colon Rectum. 2007;50(12):2158-2167.
6. Bray DA Jr, Nguyen J, Craig J, et al. Efficacy of a local anesthetic pain pump in abdominoplasty. Plast Reconstr Surg. 2007;119(3):1054-1059.
7. Charous S. Use of the ON-Q pain pump management system in the head and neck: Preliminary report. Otolaryngol Head Neck Surg. 2008;138(1):110-112.
8. Banerjee SS, Pulido P, Adelson WS, et al. The efficacy of continuous bupivacaine infiltration following arthroscopic rotator cuff repair. Arthroscopy. 2008;24(4):397-402.
9. Kazmier FR, Henry SL, Christiansen D, Puckett CL. A prospective, randomized, double-blind, controlled trial of continuous local anesthetic infusion in cosmetic breast augmentation. Plast Reconstr Surg. 2008;121(3):711-715.
10. Ciccone WJ 2nd, Busey TD, Weinstein DM, et al. Assessment of pain relief provided by interscalene regional block and infusion pump after arthroscopic shoulder surgery. Arthroscopy. 2008;24(1):14-19.
11. Acevedo Prado A, Atenzia Marino G. Local anesthetic infusion system for surgical wounds [summary]. Technical Consultation. CT2008/01. Santiago de Compostela, Spain: Galician Agency for Health Technology Assessment (AVALIA-T); 2008. 

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.