CurrentCareSourcePolicy Implantable Pain Pump-AR PASSE-MM-1502

Implantable Pain Pump-AR PASSE-MM-1502

Defines medical necessity, trialing, permanent placement, removal/revision, and contraindications for implantable intrathecal (implantable pain pump) therapy for malignant and non-malignant chronic intractable pain for CareSource Arkansas PASSE.

Policy Summary

PayerCareSource

PolicyImplantable intrathecal pain pumps (coverage criteria for trial, permanent implant, revision, removal)

Policy CodePolicy Implantable Pain Pump-AR PASSE-MM-1502

Change TypeNo material change

Effective Date06/01/2025-04/30/2026

Next Review Date

Key ActionObtain prior authorization demonstrating all clinical criteria are met before trial, implantation, revision, or removal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=50%required pain reduction to qualify for permanent pump after trial

3 monthsminimum life expectancy for malignant trial eligibility

6 monthsminimum duration of persistent pain before trial (non-malignant)

6 monthsrequired conservative therapy duration (non-malignant)

1-2 daystypical preliminary trial duration

Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when ALL of the following are met (separate rules for malignant vs non‑malignant and for trial vs permanent placement):

General medical necessity criteria for implantable pain pumps: Attempts to ameliorate physical and behavioral abnormalities which may cause an exaggerated reaction to pain have failed; the medication must require intrathecal administration and be FDA‑approved for pain management; the infusion pump must be FDA‑approved for the specific drug to be administered; the type and dosage of medication are reasonably expected to reduce the pain; implantation is performed by a physician in a facility with experience and expertise in this procedure; evaluation by an orthopedic surgeon, neurologist, neurosurgeon, oncologist, pain management physician, or other specialist familiar with the underlying disease has validated that other treatments have failed.

Preliminary trial for malignant pain (1-2 days): Member has an estimated life expectancy of at least 3 months; member is unresponsive to less invasive medical therapy including oral or subcutaneous medications (including systemic opioids) documented in the medical record; no evidence of tumor encroachment on the thecal sac or epidural metastatic lesions; no contraindications such as local infection, sepsis, or coagulopathy.

Policy Summary

PayerCareSource

PolicyImplantable intrathecal pain pumps (coverage criteria for trial, permanent implant, revision, removal)

Policy CodePolicy Implantable Pain Pump-AR PASSE-MM-1502

Change TypeNo material change

Effective Date06/01/2025-04/30/2026

Next Review Date

Key ActionObtain prior authorization demonstrating all clinical criteria are met before trial, implantation, revision, or removal.

SourceLink

On This Page

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Preliminary trial for non-malignant pain: Pain has persisted for at least 6 months; a 1- to 2-day observation stay is used for a preliminary trial of spinal opioid drug administration; pain pathology has been identified; no current drug or alcohol abuse (including opioid disorder) with at least one negative drug test within the last 3 months documented; psychological evaluation confirms pain is not due to mental health causes; surgical intervention is not indicated; oral or subcutaneous medication (including systemic opioids) was ineffective or caused intolerable side effects; failure of conservative therapy evidenced by documentation of at least 6 months of active conservative therapy within the past 12 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance, AND documentation of at least 6 months of inactive conservative therapy within the past 12 months.

Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required prior to conducting a trial, permanent implantation, revision, or removal of an implantable intrathecal pain pump. Authorization must document that ALL applicable clinical criteria in this policy are met (see policy clinical criteria for malignant and non‑malignant indications).

Prior authorization required before trial, implantation, revision, or removal
Authorization must demonstrate ALL clinical criteria in the policy are met

Step Therapy

Conservative Therapy Required Prior to Permanent Placement

Providers must document conservative and less invasive therapies attempted and failed before approval of permanent implantable pump placement for non‑malignant pain. Medical record must show either at least 6 months of active conservative therapy within the last 12 months or at least 6 months of inactive conservative therapy within the last 12 months, or inability to complete active conservative therapy due to contraindication, increased pain, or intolerance. For malignant pain, documentation must show the member was unresponsive to less invasive medical therapy (including oral or systemic opioids) and meets life expectancy and tumor/contraindication requirements.

Non‑malignant pain: ≥6 months active OR inactive conservative therapy in past 12 months OR documented inability to complete active conservative therapy
Malignant pain: documentation of failure of less invasive medical therapy (including systemic opioids)

Documentation Required

Required Documentation

Medical records must include: specialist evaluation validating other treatments have failed (orthopedic surgeon, neurologist, neurosurgeon, oncologist, pain management physician, or other appropriate specialist); indication (malignant vs non‑malignant) and supporting details (pain duration, pathology); documentation of prior failed treatments and specific conservative therapies tried (dates, modalities, and outcomes); results of psychological evaluation and drug screening when required (e.g., at least one negative drug test within past 3 months for non‑malignant pain); life expectancy estimate for malignant indications (≥3 months for trial eligibility); trial results showing ≥50% pain reduction for permanent placement; and absence of contraindications (e.g., active infection, sepsis, coagulopathy, insufficient body size, prior intolerance to implanted devices, CSF flow–blocking spinal anatomy, allergies to drug or device components, or interfering implanted programmable devices).

Specialist evaluation to validate failed treatments
Clear indication: malignant vs non‑malignant with supporting documentation
Detailed chronology and outcomes of prior conservative and less invasive therapies
Psychological evaluation and drug test results (if applicable)
Life expectancy estimate for malignant indications (≥3 months)
Trial documentation showing ≥50% pain reduction for permanent implant approval
Documentation ruling out contraindications listed in policy

Required Prior Conservative Treatments

Documented prior conservative therapies and failed less invasive treatments

Documented prior conservative therapies and failed less invasive treatments required before permanent placement (requirements differ for malignant vs non‑malignant indications):

Conservative therapy and medication trials (applies to malignant and non-malignant): Oral or subcutaneous medications (including systemic opioids) have been tried and were ineffective or caused intolerable side effects; documentation of these medication trials must be present in the medical record.

Non-malignant pain: duration and types of conservative therapies: Documentation in the medical record of at least 6 months of active conservative therapy within the past 12 months AND documentation of at least 6 months of inactive conservative therapy within the past 12 months. Active conservative therapies include physical therapy, occupational therapy, a physician‑supervised home exercise program (HEP) or chiropractic care; inactive therapies include rest, ice/heat, medical devices, TENS use, and/or pharmacotherapy. A documented inability to complete an active HEP due to contraindication, increased pain, or intolerance may substitute for completion if clearly stated and documented.

Exceptions for inability to complete active therapy: If active conservative therapy cannot be completed because of a documented contraindication, increased pain, or intolerance, the medical record must document that inability in lieu of completion of the 6‑week HEP or other active therapies.

Key Definitions

Chronic Pain

DefinitionPain that persists beyond normal healing time, lasting or recurring for more than 3 months.

ContextApplies to chronic intractable pain assessments for intrathecal therapy eligibility.

Threshold implicationMinimum duration required before trialing for non-malignant pain: 6 months (see coverage criteria).

Conservative Therapy

DefinitionA multimodality plan of care including both active and inactive conservative therapies.

Active modalitiesPhysical therapy, occupational therapy, physician‑supervised home exercise program (HEP), and/or chiropractic care.

Inactive modalitiesRest, ice/heat, medical devices, TENS use, and/or pharmacotherapy (prescription or OTC).

HEP detailHEP defined as a 6‑week program requiring an exercise prescription and follow‑up documentation after completion or documented inability to complete for valid physical reasons.

Implantable Pain Pump

DefinitionA medical device implanted under the skin that delivers medication intrathecally using a pump and catheter.

Refillable descriptionMedication can be added to the refillable pump for a continuous or variable rate (e.g., bolus) of infusion.

UseDelivers intrathecal medication to manage severe or refractory pain when other therapies have failed.

Refractory Pain

DefinitionFailure of multiple treatment therapies to reach adequate pain reduction and/or improvement in daily function.

Psychosocial requirementPsychiatric and psychosocial factors that could influence pain outcomes must have been assessed and optimized.

Role in eligibilityUsed to document refractory status before considering trialing or permanent intrathecal pump placement.

OpenPayer

Implantable Pain Pump-AR PASSE-MM-1502

Coverage and Medical Necessity Criteria

Provider Responsibilities and Authorization

Required Prior Conservative Treatments

Imaging and Trialing Requirements

Key Definitions

Clinical Background

Services Not Covered / Investigational