Implantable Infusion Pump for Pain and Spasticity

This policy addresses implantable infusion pumps (intrathecal, epidural and other routes) for long‑term continuous or intermittent drug delivery to treat severe, chronic intractable pain (including refractory cancer pain) and to manage spasticity of cerebral or spinal origin in patients intolerant of or unresponsive to less invasive therapies or oral baclofen. Coverage is limited to FDA‑approved drugs for the specific route/indication (or compounded products whose ingredients are FDA‑approved), requires a successful prior trial with an external pump or single bolus injection before permanent implantation except in cases of advanced disease/limited survival/high procedural risk, excludes experimental uses, and lists contraindications such as uncontrolled mental health disorders and active infection; note this policy version is inactive and not for current claims adjudication.

"Implantable infusion pumps to deliver drugs that are FDA‑approved for the intrathecal/epidural route for treatment of intractable pain."