LCD/NCD Portal

L31249

 

IMPLANTABLE INFUSION PUMP FOR THE TREATMENT OF CHRONIC INTRACTABLE PAIN

 

 

01/01/2013

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

This local coverage determination (LCD) addresses the use of an implantable infusion pump for treatment of chronic intractable pain and is based on the Medicare National Coverage Determinations (NCD) Manual, Infusion Pumps (Section 280.14).

 

• An implantable infusion pump is covered when used to administer opioid drugs (e.g., morphine) intrathecally or epidurally for:

o Treatment of severe chronic intractable pain of malignant or nonmalignant origin.

o In patients who have a life expectancy of at least 3 months.

o have proven unresponsive to less invasive medical therapy as determined by the following criteria:

 The patient’s history must indicate that he/she would not respond adequately to noninvasive methods of pain control, such as:

• Systemic opioids.

• Attempts to eliminate physical abnormalities which may cause an exaggerated reaction to pain.

• Behavioral abnormalities which may cause an exaggerated reaction to pain.

And

 A preliminary trial of intraspinal opioid drug administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate:

• Adequately acceptable pain relief and degree of side effects (including effects on the activities of daily living).

And

• Patient acceptance.

• Determinations may be made on coverage of other uses of implanted infusion pumps if the contractor’s medical staff verifies that:

o The drug is reasonable and necessary for the treatment of the individual patient.

o It is medically necessary that the drug be administered by an implanted infusion pump.

o The Food and Drug Administration (FDA)-approved labeling for the pump must specify that the drug being administered and the purpose for which it is administered is an indicated use for the pump.

 

Additionally, antispasmodic drugs for severe spasticity used concomitantly for treatment of chronic intractable pain must meet the following NCD criteria:

• An implantable infusion pump is covered when used to administer anti-spasmodic drugs intrathecally (e.g., baclofen) to treat chronic intractable spasticity in patients who have proven unresponsive to less invasive medical therapy as determined by the following criteria:

o As indicated by at least a 6-week trial.

o The patient cannot be maintained on noninvasive methods of spasm control, such as oral anti-spasmodic drugs, either because:

 These methods fail to control adequately the spasticity.

Or

 Produce intolerable side effects.

o Prior to pump implantation, the patient must have responded favorably to a trial intrathecal dose of the anti-spasmodic drug.

 

 

Coding Information

 

CPT/HCPCS Codes

 

62367 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITHOUT REPROGRAMMING OR REFILL

62368 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING

62369 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL

62370 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL (REQUIRING SKILL OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL)

95990 REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR FOR DRUG DELIVERY, SPINAL (INTRATHECAL, EPIDURAL) OR BRAIN (INTRAVENTRICULAR), INCLUDES ELECTRONIC ANALYSIS OF PUMP, WHEN PERFORMED;

95991 REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR FOR DRUG DELIVERY, SPINAL (INTRATHECAL, EPIDURAL) OR BRAIN (INTRAVENTRICULAR), INCLUDES ELECTRONIC ANALYSIS OF PUMP, WHEN PERFORMED; REQUIRING SKILL OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

 

 

Documentation Requirements

 

• Medical record documentation maintained by the performing provider must clearly indicate the medical necessity of the services being billed as outlined under the “Indications and Limitations of Coverage and/or Medical Necessity” section of this LCD and made available upon request.

o In addition, documentation that the service was performed must be included in the patient’s medical record and should be legible.

o This information is normally found in the history and physical, office/progress notes, and/or procedure report.

• All of the CPT codes related to the refilling and maintenance of the pump should be billed and documented on the same claim form along with the procedure code for the drugs that are administered through the pump.

o It is expected that all of these codes should be billed on the same claim.

• Note: See “Coding Guidelines” section of this LCD for coding and billing instructions (e.g., use of unique HCPCS drug code(s) vs. unlisted drug code, reconstituted vs. compounded, etc.).

 

 

Treatment Logic:

• The implantable infusion pump is a drug delivery system that is used to deliver a solution containing a parenteral drug(s) under continuous or intermittent infusion with a regulated flow rate.

o Its purpose is to deliver a therapeutic level of a drug to a specific site within the body.

 

 

Sources of Information and Basis for Decision

 

“Implantable Infusion Pump for Treatment of Chronic Intractable Pain,” Palmetto GBA LCD (01102) L28268.

 

Cohen, S.P., & Dragonish, A. (2007). Intrathecal Analgesia. Medical Clinics of North America. 91(2), 251-270. Retrieved May 3, 2010 from www.mdconsult.com.

 

FCSO LCD 31254, Implantable Infusion Pump for the Treatment of Chronic Intractable Pain, 01/01/2013

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Stearns, L., Boortz-Marx, R., Du Pen, S., Friehs, G., Gordon, M., Halyard, M., Herbst, L., & Kiser, J. (2005). Intrathecal Drug Delivery for the Management of Cancer Pain: A Multidisciplinary Consensus of Best Clinical Practices. The Journal of Supportive Oncology. 3(6), 399-408. Retrieved April 30, 2010 from www.SupportiveOncology.net.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD IMPLANTABLE INFUSION PUMP FOR THE TREATMENT OF CHRONIC INTRACTABLE PAIN