CG-SURG-79 Implantable Infusion Pumps

Implantable infusion pumps are covered for specific medically necessary treatments, including intrahepatic chemotherapy for liver cancer, severe spasticity, and chronic pain management following a trial of other analgesics. Key requirements include clinical documentation of diagnosis, a successful trial of previous treatments, and evidence of clinical benefit for device replacements or revisions. Limitations exclude coverage for non-pump systems, cases lacking adequate trial documentation, and convenience-driven upgrades when current devices remain functional.

"Medically necessary for treatment of primary liver cancer through intrahepatic artery injection of chemotherapeutic agents."

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