Implantable Intrathecal or Epidural Pain Pump

This policy covers implantation of an intrathecal or epidural drug‑delivery (implantable pain pump) system for long‑term management of select patients with intractable malignant or nonmalignant chronic pain (e.g., failed back surgery syndrome, complex regional pain syndrome) after conservative therapies have failed. Coverage requires a successful preliminary epidural/intrathecal trial demonstrating ≥50% pain reduction with minimal side effects, ≥50% reduction in systemic opioids (with a continued weaning plan), appropriate life expectancy (for malignancy), psychological clearance, and excludes patients with active infection or coagulopathy, active substance abuse or opioid addiction, major psychiatric contributors to pain, inadequate body habitus, incompatible implanted devices, or allergies to device materials or medications.

"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."