1)
Implantable infusion pumps are considered medically necessary and
are covered when used to deliver drugs having FDA approval or recommendation by
the AHFS or Clinical Pharmacology Online drug compendia and for the related
indication for the treatment of:
a.
Primary liver cancer (intrahepatic artery injection of
chemotherapeutic agents);
b.
Metastatic colorectal cancer where metastases are limited to the
liver (intrahepatic artery injection of chemotherapeutic agents);
c.
Head/neck cancers (intra-arterial injection of chemotherapeutic
agents);
2)
Implantable infusion pumps are considered medically necessary and
are covered for patients with severe, chronic, intractable (non-cancer related)
pain (e.g., morphine, clonidine, buprenorphine, Ziconotide, fentanyl) when:
a.
The member has had a
thorough evaluation to categorize the cause(s) of chronic pain and participated
in a comprehensive treatment plan tailored to individual needs.
b.
There is
documentation of trial and failure of all of the following alternatives to
outpatient opioid maintenance therapy for chronic pain:
i)
Multidisciplinary pain rehabilitation.
ii)
Physical
treatments (eg, monitored exercise therapy, weight loss)
iii)
Psychological treatments (eg, cognitive behavioral therapy, relaxation
techniques, stress-reduction techniques)
iv)
Non-opioid
medications (eg, nonsteroidal anti-inflammatory drugs (NSAIDs), tricyclic
antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs),
anticonvulsants)
c.
Member is determined to be suitable candidate for long-term opioid
analgesia and the benefits outweigh risks based on assessments including for
high risk for opioid misuse validated screening instruments (such as DIRE > 13,
ORT < 8, or SOAPP-R < 18).
d.
Member has no contraindications to opioid therapy. Absolute
contraindications to opioid therapy include severe respiratory instability,
acute psychiatric instability or uncontrolled suicide risk, diagnosed
substance-related disorder (other than nicotine) not in remission or for which
the patient currently is receiving active treatment, opioid allergy that cannot
be resolved by switching agents, co-administration of a drug capable of inducing
life-threatening drug-drug interaction, QTc interval greater than 500
milliseconds (for methadone), active diversion of controlled substances (ie,
providing medication to someone for whom it was not prescribed), or history of
prior opioid trials that were discontinued (eg, due to intolerance,
non-treatable serious adverse effects, or lack of efficacy).
e.
The patient been tried on and is unable to get adequate pain relief
or has unacceptable side effects from short acting and
long acting opioids. Please refer to BI566 Short Acting Opioids and BI583 Long
acting Opioids, for specific criteria. ; AND
f.
Only medication that are FDA approved for intrathecal use may be
used for intrathecal pumps.
g.
Renewal of Intrathecal medications: Requests for continuation of
intrathecal infusion medications require:
i.
Member continues to meet criteria for long term opioid therapy per
BI583 and for and appropriate dosing based on standard Centers for Disease
Control and Prevention (CDC) guidelines for Opioid Prescribing for Chronic Pain
AND The Polyanalgesic Consensus Conference (PACC): Recommendations on
Intrathecal Drug Infusion Systems Best Practices and Guidelines.
ii.
There is no documentation of opioid abuse as indicate by opioid
misuse screening tools scores ((such as DIRE > 13, ORT < 8, or SOAPP-R < 18) and
by regular checks of the Arkansas Prescription Monitoring Program (PMP) by the
provider.
iii.
Member continues to have 50% or greater improvement in functional
capacity.
iv.
At any time a member does not meet the Opioid Misuse screening
scores screening instruments (such as DIRE > 13, ORT < 8, or SOAPP-R < 18),
she/he will no longer be considered a suitable candidate for long term opioid
therapy and should be referred to a substance rehab program.
h.
The infusion pump is used as one part of an integrated pain
management program; AND
i.
The pump is being managed by a board certified pain management
specialist; AND
j.
Use of an implantable pump for epidural or intrathecal infusion
requires a successful trial (at least 50% reduction in pain and improvement in
function) of short term epidural or intrathecal injection.
3)
Implantable infusion pumps are covered when used to provide
intrathecal injection of baclofen in patients with severe spasticity of cerebral
or spinal cord origin in patients who are unresponsive to or who cannot tolerate
oral baclofen therapy
a.
A successful trial (at least 50% reduction in spasticity and
improvement in function) of intrathecal injection of baclofen must precede
implantation.
4)
Cancer diagnoses require a life expectancy of at least three
months.
5)
Supplies for an Implantable Infusion pump do not require
preauthorization.
Codes
Used In This BI:
|
36260 |
Insertion of implantable intra-arterial infusion pump (e.g., for
chemotherapy of liver) |
|
61215 |
Insertion of subcutaneous reservoir, pump or continuous infusion system
for connection to ventricular catheter |
|
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 |
|
62361 |
Implantation or replacement of device for intrathecal or epidural drug
infusion; nonprogrammable pump |
|
62362 |
Implantation or replacement of device for intrathecal or epidural drug
infusion; programmable pump, including preparation of pump, with or
without programming |