CMM-210: Implantable Intrathecal Drug Delivery Systems

This policy covers implantable intrathecal or epidural drug delivery systems for nonmalignant chronic intractable pain, severe refractory spasticity/chronic dystonia (intrathecal baclofen), and cancer‑related pain when criteria are met, and excludes use for chemotherapy/antibiotic administration, other indications that don’t meet criteria, obstetrical/surgical epidural anesthesia, and pump replacement when the existing device remains functional. Key requirements include documented pathology and failure of specified conservative treatments (≥6 months noninvasive care for nonmalignant pain; ≥6 weeks oral antispasmodics + PT for spasticity), a successful percutaneous trial (>50% pain reduction for 8 hours for pain or ≥2‑point Ashworth/Spasm Frequency reduction for 4 hours for spasticity) before permanent implantation, agreement to a 50% opioid reduction prior to intrathecal opioid trials, and detailed documentation for case‑by‑case review (with trial waived for advanced/high‑risk cancer).