CMM-210: Implantable Intrathecal Drug Delivery Systems

Evicore covers implantable intrathecal or epidural drug delivery systems for nonmalignant chronic intractable pain, severe refractory spasticity/chronic dystonia, and cancer-related pain (excluding obstetrical/surgical anesthesia and experimental indications) when medical necessity is documented. Key requirements include documented pathology, prior conservative therapy (typically ≥6 months for nonmalignant pain; ≥6 weeks of oral antispasmodics + PT or qualifying baseline Ashworth/spasm scores for spasticity), a successful percutaneous trial (≥50% pain reduction with improved function for pain/cancer; ≥2‑point Ashworth/spasm reduction for spasticity), agreement to a 50% systemic opioid reduction before intrathecal opioid trial, behavioral-health clearance, and adherence to specified documentation and replacement criteria (trial may be waived in advanced cancer/high procedural risk).

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