C1772 — Infusion pump, programmable (implantable)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation of failure of or intolerance to conservative treatments (e.g., systemic medications, physical therapy, behavioral health interventions).
- Records demonstrating compliance with prior treatment attempts for the condition.
- Psychological evaluation report documenting that mental health is not a major contributor to the pain condition.
- Documentation showing systemic opioid dose was reduced/weaned by at least 50% prior to trial.
Key Coverage Criteria
- Long-term management of select patients with intractable pain using an implanted intrathecal or epidural drug delivery system that delivers medication directly into the spinal fluid.
- Preliminary trial of epidural or intrathecal opioid for chronic intractable pain of malignant origin when: inadequate response to or intolerable side effects from noninvasive methods of pain control (e.g., systemic opioids); life expectancy > 3 months; and no evidence of epidural metastatic lesion(s) or tumor encroachment of the thecal sac on imaging.
- Preliminary trial of epidural or intrathecal opioid for chronic intractable pain of nonmalignant origin (e.g., failed back surgery syndrome, complex regional pain syndrome) when: the pathology for the pain has been identified and life expectancy > 3 months.
- Chronic pain refractory to or unable to tolerate conservative treatments (systemic pharmacotherapy, physical therapy, behavioral health for pain, and other appropriate nonsurgical treatments).
- Member has demonstrated compliance with previous attempts to treat the condition.
- Psychological evaluation confirms that a mental health condition is not a major contributor to the chronic pain symptoms.
1 Active Policy
AMBETTER-CP.MP.173 — Implantable Intrathecal or Epidural Pain Pump
Related Codes
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