Intrathecal Baclofen Therapy - MEDICAID - LOUISIANA

This policy covers intrathecal baclofen (ITB) therapy, including surgical implantation of a programmable infusion pump for delivery of ITB. It is indicated for severe spasticity of spinal cord or cerebral origin (e.g., cerebral palsy, multiple sclerosis, spinal cord injury, dystonia) in patients aged ≥4 years with sufficient body mass who demonstrate a positive intrathecal test dose and required Ashworth scale improvement (≥2 for spinal, ≥1 for cerebral), are refractory to or intolerant of oral/conservative therapies, and meet other medical necessity criteria; exclusions/precautions include cerebral injury <1 year, more than mild athetosis, history of autonomic dysreflexia, psychotic disorders, or incompatible implanted devices.

"By implication, candidates under 4 years of age or those without sufficient body mass are not eligible per this policy statement"

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