CMM-210: Implantable Intrathecal Drug Delivery System

Cigna/eviCore covers implantable intrathecal or epidural drug delivery systems for non‑malignant chronic intractable pain, severe refractory spasticity/chronic dystonia, and cancer‑related pain, but excludes obstetrical/surgical epidural anesthesia and use for specified injectates (e.g., Spinraza, chemotherapy, neurolytic agents, antibiotics/antivirals, biologics, etc.). Coverage requires documented conservative therapy and specific trial/response criteria: non‑malignant pain needs ≥6 months of provider‑directed non‑invasive care including active rehabilitation and fixed‑schedule opioids (unless contraindicated), patient agreement to a 50% systemic opioid reduction before trial, and a trial showing >50% pain reduction for 8 hours plus functional gain for permanent implant; spasticity requires failed/intolerant ≥6‑week oral antispasmodic + PT (unless contraindicated), baseline Ashworth ≥3 (Modified ≥2) and Penn Spasm ≥2 with a ≥2‑point Ashworth or Spasm Frequency improvement for 4 hours post‑baclofen for permanent therapy; cancer pain requires failure/intolerance of non‑invasive measures and ≥50% pain reduction on trial for permanent implantation.