C2626, Infusion pump, non-programmable, temporary (implantable)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation that the existing device cannot be repaired, or that the patient's condition has changed making the present device nonfunctional.
- Documentation supporting impending end of battery life if that is cited as the reason for replacement.
- Objective documentation of device malfunction or catheter migration/kink, such as rotor/catheter dye studies or imaging studies.
- See the Related CMS Documents Section above for any such NCDs or LCDs
Key Coverage Criteria
- Use of single use elastomeric or springloaded devices for delivery of continuous regional anesthesia for postoperative pain control.
- Use of devices that allow bolus injections with adjustable lockout times (newer models) for postoperative analgesia.
- Implantable infusion pumps for management of spasticity (contextual: Appendix B provides Ashworth Scale for spasticity assessment)
- Inferred from policy_id: implantable infusion pumps for management of chronic pain or spasticity (inference only; not stated in the fragment).
- Implantable infusion pumps for chronic pain (as indicated by article title: 'Billing and Coding: Implantable Infusion Pumps for Chronic Pain').
- Implantable infusion pumps for pain
1 Active Policy
HUMANA-IMPLANTABLE-INFUSION-PUMPS-FOR-PAIN-OR-SPASTICITY-MA, Implantable Infusion Pumps for Pain or Spasticity
Related Codes
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