Removal of Ascites via Implantable Pump

This policy addresses implantation and use of a subcutaneous peritoneal-to-bladder pump system (e.g., alfapump) to continuously transfer ascitic fluid from the peritoneal cavity into the bladder for elimination. It is intended for adults with refractory or recurrent ascites—primarily due to liver cirrhosis—or malignant ascites in patients with limited life expectancy, and for those requiring frequent large-volume paracenteses; it is not for individuals under 18 or who may be pregnant and use is limited to a maximum of 2 years. Major limitations: the alfapump is not FDA‑approved, evidence is limited to small short-term studies with reported surgical/device complications (including prerenal insufficiency), the therapy is considered experimental/investigational and not covered for cirrhotic refractory/recurrent ascites in this policy version, which is inactive and not to be used for current claims adjudication.

"Ascites due to portal hypertension: accumulation of abdominal fluid with risk of spontaneous bacterial peritonitis."