RetiredCapital BluecrossPolicy MP 1.058

Implantable infusion pumps for pain and spasticity

This policy governs medical necessity and coverage stance for surgically implanted infusion pumps used to deliver FDA‑approved drugs for treatment of severe chronic intractable pain and severe spasticity, and specifies investigational uses that are not supported.

Policy Summary

PayerCapital Bluecross

PolicyImplantable infusion pumps for pain and spasticity

Policy CodePolicy MP 1.058

Change TypeRetirement

Effective DateRETIRED 5/1/2026

Next Review DateN/A

Key ActionObtain prior authorization for listed implantable infusion pump procedure and device codes before implantation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2medically necessary indications

Multiple codescoding included

Retired 5/1/26policy status

≥1guideline refs

MP 1.058policy id

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Coverage Criteria for Implantable Infusion Pumps

Medically necessary indications

Covered when ALL of the following are met for the respective indication

Pain indication: Severe, chronic, intractable pain (cancer or noncancer) to be treated with intravenous, intrathecal, or epidural infusion of opioids via an implantable infusion pump

Must follow a successful temporary trial by the same route of administration defined as >50% reduction in pain

Spasticity indication: Severe spasticity of cerebral or spinal cord origin in patients unresponsive to or intolerant of oral baclofen therapy to be treated with intrathecal baclofen via an implantable infusion pump

Oral baclofen trial with documented failure or intolerance required

Investigational indications

Not covered / investigational

Investigational uses: Implantable infusion pumps are considered investigational for all other uses related to pain and spasticity

Insufficient evidence to support uses beyond the listed medically necessary indications

Use of implantable infusion pumps for indications other than the specific medically necessary indications listed in this policy is considered investigational and is not covered. The policy’s medically necessary indications are limited to: (1) severe, chronic, intractable pain (intravenous, intrathecal, or epidural opioid administration) following a documented successful temporary trial (>50% reduction in pain) by the same route, and (2) severe spasticity of cerebral or spinal cord origin in patients unresponsive to or intolerant of oral baclofen with treatment via intrathecal baclofen. Use of implantable pumps for other pain or spasticity indications lacks sufficient evidence to support health outcomes and may be denied as investigational.

The FDA has issued a safety communication advising caution when considering medicines for use in implanted intrathecal pumps. The FDA specifically calls attention to medications not approved for intrathecal administration (for example, hydromorphone, bupivacaine, fentanyl, clonidine) and warns that compounded medications or any mixture of two or more different medications for pump delivery are not approved. Providers should therefore be cautious about using non‑FDA‑approved intrathecal medications or compounded admixtures with implantable infusion pumps, as these combinations raise safety concerns and may lead to exclusion or denial.

There is insufficient evidence to determine the effects of implantable infusion pumps for indications beyond the covered uses of cancer-related or chronic intractable pain and severe spasticity. The policy states that implantable infusion pumps are considered investigational for all other uses related to pain and spasticity because current evidence does not support a general conclusion about benefits or health outcomes.

Procedure, Supply, and Diagnosis Codes

Covered CPT/HCPCS/Procedure/Supply CodesmixedCovered

62369	Procedure Code (listed under covered when medically necessary)
62351	Procedure Code
62370	Procedure Code
62355	Procedure Code
95990	Procedure Code
62360	Procedure Code
95991	Procedure Code
62361	Procedure Code
A4220	Supply
62362	Procedure Code

1–10 of 25

1/3

Relevant ICD-10 Diagnosis CodesICD-10

G04.1	Tropical spastic paraplegia
G35	Multiple sclerosis
G35.B	Primary progressive multiple sclerosis
G35.C	Secondary progressive multiple sclerosis
G56.40	Causalgia of unspecified upper limb
G56.41	Causalgia of right upper limb
G56.42	Causalgia of left upper limb
G56.43	Causalgia of bilateral upper limbs
G57.70	Causalgia of unspecified lower limb
G57.71	Causalgia of right lower limb

1–10 of 38

1/4

Updated codes listed in policy historymixed

C9811

Code added effective 01/01/2026 (description not provided in excerpt)

Successful temporary trial (inv-09)

Successful temporary trial — definitionDefined as greater than 50% reduction in pain following implementation of treatment by the same route as planned for implantation

Required for pain indicationA successful temporary trial is required prior to implantation for severe, chronic, intractable pain (intravenous, intrathecal, or epidural opioid or non-opioid trials)

Route matching requirementTrial must use the same route of administration as the planned implantable infusion pump therapy

Provider Actions, Documentation, and Billing Notes

Prior Authorization

Prior Authorization Required

Prior authorization is implied for the procedures and device codes listed in the policy; verify PA requirements with the payer prior to scheduling.

Affected procedure/device codes listed in coding section — ensure PA is obtained when required.
Administrative coding updates (see policy history) may change which codes require PA.

Documentation Required

Documentation and Conservative Therapy Requirements

Document and retain evidence of a successful temporary trial and required conservative therapy before implantation. For spasticity, patients must be unresponsive to or intolerant of oral baclofen prior to consideration for intrathecal baclofen pump implantation.

Required documentation: description of temporary trial (route matched to planned treatment), trial outcome showing >50% pain reduction for pain indications.
For spasticity: documentation of oral baclofen trial and reason for intolerance or failure.

Step Therapy

Step therapy: no formal step-therapy program is specified in this policy excerpt. Follow standard conservative management steps noted in the policy (e.g., temporary trial for pain; oral baclofen for spasticity) before implantation.

No additional payer-specific step therapy requirements are listed in this policy.
Providers should still document prior conservative treatments and trials in the medical record.

Billing Rule

Coding Updates and Billing Rules

Coding and billing must reflect current code sets; administrative updates in the policy history have added and revised procedure and ICD-10 codes which can affect PA processes and claim adjudication.

Recent administrative updates added new ICD-10 codes effective 10/01/2025 and HCPCS/CPT adjustments (e.g., addition of C9811 effective 01/01/2026).
Verify code-to-service mapping and PA requirements after each coding update to avoid claim denials.

Denial Risk

Denial Risk and Common Triggers

Potential triggers for claim denial include use of the pump for indications not supported by the policy, lack of required temporary trial documentation for pain, or absent documentation of failure/intolerance of oral baclofen for spasticity. Coding mismatches after administrative updates may also lead to denials.

Unapproved indications or use of medications not FDA-approved for intrathecal administration (see FDA safety communication).
Missing documentation of successful temporary trial (>50% pain reduction) or lack of documented oral baclofen trial/intolerance for spasticity.
Use of outdated or incorrect codes following coding updates.

Note

Supporting References

Key supporting references that inform coverage and safety considerations are provided; consult these for evidence, safety communications, and guideline context when preparing prior authorization requests and clinical documentation.

FDA safety communication (Nov 14, 2018) regarding caution with implanted pumps for intrathecal administration of medicines not approved for such use.
Systematic reviews and guideline references (Pain Physician, NICE, NCCN where applicable) cited in the references section.
Selected clinical studies and complication reports relevant to intrathecal baclofen and infusion pumps are listed in the policy references.

Conservative Treatment and Trial Requirements

Successful trial required prior to implantation

A successful temporary trial is required prior to device implantation for pain indications

Successful temporary trial (pain): Evidence of a successful temporary trial by the same route of administration as planned for the implantable pump>50% reduction in pain

Trial may use opioid or non-opioid analgesics; documented >50% pain reduction is required before implantation

Conservative therapy duration / specific therapy requirements

Document excerpt does not specify duration or a required sequence of conservative therapies beyond the trial requirements described above

Conservative therapy duration/sequence: No specific conservative treatment duration or defined stepwise therapy sequence is specified in the provided policy excerpt

For spasticity, oral baclofen trial and failure/intolerance is required; otherwise the document does not list specific therapy durations or additional conservative therapy requirements

Imaging and Procedural Notes

Documentation Required

Document pump implant site and catheter position (intrathecal vs epidural)

The pump is implanted in a subcutaneous pocket (infraclavicular fossa or abdominal wall) and a catheter is threaded to the desired position; catheter position may be intrathecal (subarachnoid space) or epidural — document implant site and catheter position in procedural notes.

Implant locations: infraclavicular fossa or abdominal wall.
Catheter positions: intrathecal (in subarachnoid space) or epidural.

Note

Imaging details for implantation not specified in excerpt

Imaging procedural details (fluoroscopy use or specific imaging protocols) are not specified in the provided excerpt; the policy notes catheter placement and implant locations but does not provide additional imaging requirements.

Procedural imaging specifics are not detailed in this portion of the document.
Fluoroscopy is noted elsewhere as required for interventional pain procedures, but no imaging protocol is listed here.

Key Definitions

Intrathecal (inv-19)

Definition — intrathecalAdministration within the cerebrospinal fluid contained by the dura mater (subarachnoid space); intrathecal catheter position is in this space and differs from epidural placement

Catheter position noteIntrathecal catheter is threaded into the subarachnoid space (passes through epidural space and dura mater into the theca of the spinal cord)

Contrast with epiduralEpidural position is outside or above the dura mater and is distinct from intrathecal placement

Infusion pump (inv-20)

Device definitionA surgically implanted device intended to provide long-term continuous or intermittent drug infusion; reservoir refillable percutaneously through a self-sealing septum

Programmable featuresThe pump can be programmed to set constant or variable rates of administration according to physician specifications

Routes of administrationPossible routes include intravenous, intra-arterial, subcutaneous, intraperitoneal, intrathecal, and epidural

Intrathecal infusion systems (inv-21)

TerminologyIntrathecal infusion systems are implantable infusion pumps used for long-term intraspinal drug delivery (intrathecal and epidural routes)

Device family characteristicsIncludes surgically implanted reservoir, refillable septum, catheter threaded to desired position, and various driving mechanisms (peristalsis, propellant, osmotic, piezoelectric, etc.)

Implant locationsTypically implanted in a subcutaneous pocket under the infraclavicular fossa or in the abdominal wall with catheter routed to intraspinal position

OpenPayer