CurrentArizona Complete HealthPolicy CP.MP.173

Implantable Intrathecal or Epidural Pain Pump (implantation and trialing)

Medical necessity criteria for trialing and permanent implantation of implantable intrathecal or epidural opioid (and non-opioid adjunct) drug delivery systems for chronic malignant and nonmalignant pain for health plans affiliated with Centene Corporation (Arizona Complete Health).

Policy Summary

PayerArizona Complete Health

PolicyImplantable Intrathecal or Epidural Pain Pump (implantation and trialing)

Policy CodePolicy CP.MP.173

Change TypeRestructure and criteria updates

Effective Date

Next Review Date

Key ActionDocument a preliminary epidural or intrathecal trial demonstrating >= 50% pain reduction (and for nonmalignant pain, increased function) with minimal side effects before requesting permanent implantation, and document failed conservative therapies and absence of listed contraindications.

SourceLink

POLICY UPDATE CHANGES

Restructured and reformatted criteria sections and added explicit contraindications including known allergies to implant materials, active substance abuse, dementia/psychosis, active systemic infection, and active infection at implantation site.

Removed criterion requiring active participation in psychotherapeutic interventions from trial criteria (I.A.2.f).

>=50%Pain reduction threshold to consider trial or permanent implantation successful

>3Minimum life expectancy required for malignant pain indication

2Indication categories covered

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medical Necessity Criteria for Trial and Implantation

I. Trial of epidural or intrathecal administration (preliminary trial)

A preliminary trial is medically necessary when ALL of the following are met:

ALL of the following

Indication (one of)
- 1. Chronic intractable pain of malignant origin
  - Inadequate response to, or intolerable side effects from, noninvasive methods of pain control such as systemic opioids
  - Life expectancy > three months> 3 months
  - No evidence of epidural metastatic lesion(s) or tumor encroachment of the thecal sac by imaging
- 2. Chronic intractable pain of nonmalignant origin
  - Pathology for the pain has been identified
  - Life expectancy is > three months> 3 months
  - Failure or inability to tolerate other conservative treatment methods, including but not limited to, systemic pharmacotherapy, physical therapy, behavioral health treatment for pain, and appropriate nonsurgical treatment
  - Compliance with previous attempts to treat the condition
  - A psychological evaluation confirms a mental health condition is not a major contributor to chronic pain symptoms
Contraindications (none of the following)
- Known allergies to materials in the implant
- Active alcohol or drug abuse, including but not limited to opioid addiction and intravenous drug abuse
- Diagnosis of dementia or psychosis
- Active systemic infection
- Active infection at the site of implantation

II. Permanent implantation of epidural or intrathecal pump

Permanent implantation is medically necessary when ALL of the following are met:

ALL of the following

Indication (one of)
- 1. Chronic intractable pain of malignant origin
  - The above criteria for the preliminary trial are met
  - The trial provided ≥ 50% reduction in pain with minimal side effects>= 50% reduction
  - Body size is sufficient to support the weight and bulk of the device

Note on malignant pain trial requirement exception

Exception/medical director review:

ALL of the following

The trial requirement for a percutaneous intrathecal or epidural drug delivery system for pain of malignant origin may be reviewed by a medical director on a case-by-case basis for instances of advanced disease, when survival time is limited, or when the patient is considered high risk for procedures

Relevant Procedure and Supply Codes

CPT Codes (procedures referenced)CPT

62320	Injection(s), interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62321	Injection(s), interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance
62322	Injection(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62323	Injection(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance
62326	Injection(s), including indwelling catheter placement... lumbar or sacral; without imaging guidance
62327	Injection(s), including indwelling catheter placement... with imaging guidance
62350	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter; without laminectomy
62351	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter; with laminectomy
62355	Removal of previously implanted intrathecal or epidural catheter
62360	Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir

1–10 of 17

1/2

HCPCS / DME / Supply Codes referencedHCPCS

A4300	Implantable access catheter, external access
A4301	Implantable access total catheter, port/reservoir
E0782	Infusion pump, implantable, nonprogrammable
E0783	Infusion pump system, implantable, programmable
E0785	Implantable intraspinal catheter used with implantable infusion pump, replacement
E0786	Implantable programmable infusion pump, replacement
C1772	Infusion pump, programmable (implantable)
C1755	Catheter, intraspinal
J2274	Injection, morphine sulfate, preservative free for epidural or intrathecal use, 10 mg
S0093	Injection, morphine sulfate, 500 mg (loading dose for infusion pump)

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Preliminary trial required prior to permanent implant

A documented preliminary epidural or intrathecal trial demonstrating >= 50% pain reduction (and for nonmalignant pain, increase in function) with minimal side effects is required before permanent implantation except when medical director review approves bypass in select advanced malignant disease cases.

62320
62321
62322
62323
62326
62327

Documentation Required

Documentation of failed conservative therapy and psychosocial evaluation

Providers must document failure or intolerance of conservative treatments, evidence that pathology for the pain has been identified, compliance with prior treatments, psychological evaluation confirming a mental health condition is not a major contributor to symptoms, and that opioid-induced hyperalgesia has been ruled out.

Numeric and Clinical Thresholds

Key Thresholds

Trial pain reduction>= 50% reduction in pain

Wean systemic opioids prior to trial>= 50% reduction in systemic opioid dose

Life expectancy for malignant indication> 3 months

Clinical Background and Scope

Implantable intrathecal and epidural drug delivery systems consist of an implanted catheter and pump that deliver medication directly into the spinal fluid to provide targeted long-term analgesia for select patients with recalcitrant chronic pain. These systems are most commonly used for cancer-related (malignant) pain and are considered an invasive option after other conservative and surgical therapies have failed (see device description and implantation technique).

Use of intrathecal/epidural pumps for chronic nonmalignant pain is controversial and generally reserved as a last-resort option for patients who have exhausted less invasive treatments. The evidence base for long-term benefit in noncancer pain is limited and consists mainly of observational and retrospective studies; large randomized controlled trials demonstrating superiority over systemic therapy are lacking.

A preliminary percutaneous trial of epidural or intrathecal administration is required before permanent implantation in most cases. The trial is intended to demonstrate an adequate predefined improvement in pain—typically ≥ 50% pain reduction—without intolerable adverse effects; for nonmalignant pain the trial should also demonstrate an increase in function. For malignant pain, a medical director may waive the percutaneous trial requirement in selected cases of advanced disease, limited life expectancy, or high procedural risk.

Defined Terms

Definitions

Chronic painPain that persists longer than six months or beyond the usual course of an acute disease or reasonable time for an injury to heal.

Trial (preliminary trial)A temporary epidural or intrathecal infusion, with or without catheter, to determine whether the patient obtains an adequate response (typically >=50% pain reduction) without intolerable adverse effects.

Policy Changes and Revision Notes

01/24revised

Annual review: Restructured and reformatted criteria sections; added explicit contraindications including known allergies to implant materials, active alcohol or drug abuse (including opioid addiction and IV drug use), dementia/psychosis, active systemic infection, and active infection at implantation site; background updated with no impact to criteria.

11/24revised

Annual review: Removed criterion I.A.2.f requiring active participation in psychotherapeutic interventions from trial criteria; minor grammatical edits to criteria I.A.2.h and II.A.2.i; background and references updated.

01/23revisedLatest

Policy Summary

PayerArizona Complete Health

PolicyImplantable Intrathecal or Epidural Pain Pump (implantation and trialing)

Policy CodePolicy CP.MP.173

Change TypeRestructure and criteria updates

Effective Date

Next Review Date

SourceLink

On This Page

Further surgical intervention or other treatment is not indicated or likely to be effective

Prior to the trial, systemic opioids have been weaned by at least 50%>= 50% reduction

Opioid induced hyperalgesia has been ruled out as a possible cause of the chronic pain symptoms

No other implanted programmable devices for which the interaction between devices may inadvertently change the prescription

No known allergy or hypersensitivity to the drug being used

2. Severe chronic pain of non-malignant origin

The above criteria for the preliminary trial are met
Preliminary trial provided ≥ 50% reduction in pain and increase in function with minimal side effects>= 50% reduction
There is a plan in place to continue to wean systemic opioids
No active coagulopathy
Body size is sufficient to support the weight and bulk of the device
No other implanted programmable devices for which the interaction between devices may inadvertently change the prescription
No known allergy or hypersensitivity to the drug being used
No evidence of increased intracranial pressure
No spinal anomalies that may complicate the implantation and fixation of a catheter for drug delivery
Continued active participation in any behavioral health or psychological treatment modalities

Contraindications (none of the following)

Known allergies to materials in the implant
Active alcohol or drug abuse, including but not limited to opioid addiction and intravenous drug abuse
Diagnosis of dementia or psychosis
Active systemic infection
Active infection at the site of implantation

Denial Risk

Contraindications lead to non-coverage

Requests will be denied if the patient has any of the listed contraindications; these contraindications must be absent for coverage.

Known allergies to materials in the implant
Active alcohol or drug abuse (including opioid addiction and IV drug use)
Diagnosis of dementia or psychosis
Active systemic infection
Active infection at the site of implantation

Documentation Required

Body habitus and device interaction assessment

For permanent implantation document that body size is sufficient to support the weight and bulk of the device and that there are no other implanted programmable devices that could interact and alter therapy.

62360
62361
62362
Document body habitus sufficient for device weight/bulk
Document absence of other implanted programmable devices that may interact

Documentation Required

Plan for opioid weaning (nonmalignant pain)

For nonmalignant pain, document a plan in place to continue to wean systemic opioids after implantation.

Annual review: References reviewed and updated; minor rewording and format changes with no clinical significance; ICD-10 table removed and title updated to 'Implantable Intrathecal or Epidural Pain Pump.'

Implantable Intrathecal or Epidural Pain Pump (implantation and trialing)

Medical Necessity Criteria for Trial and Implantation

Relevant Procedure and Supply Codes

Prior Authorization, Documentation, and Denial Risks

Numeric and Clinical Thresholds

Clinical Background and Scope

Defined Terms

Policies to Read With

Policy Changes and Revision Notes