CurrentColorado Rocky Mountain Health Plans | UnitedHealthcarePolicy 2026T0626M

Implanted Spinal Drug Delivery Systems (Intrathecal/Epidural Drug Infusion Systems)

Policy Summary

PayerColorado Rocky Mountain Health Plans | UnitedHealthcare Commercial and Individual Exchange

PolicyImplanted Spinal Drug Delivery Systems (Intrathecal/Epidural Drug Infusion Systems)

Policy CodePolicy 2026T0626M

Change TypeTemplate Update

Effective DateJan 1, 2026

Next Review Date

Key ActionFor cancer-related pain and severe spasticity, refer to and document that InterQual CP: Procedures, Epidural or Intrathecal Catheter Placement criteria are met to support medical necessity; document trial response (>50% pain reduction) and required conservative therapy/psychosocial evaluation for chronic non-malignant pain.

POLICY UPDATE CHANGES

Template Update: Created shared policy version to support application to Oxford plan membership and archived previous policy version 2025T0626L and PHARMACY 339.9.

3Covered Indications (Cancer pain, Spasticity, Chronic non-malignant pain)

50%+Required trial pain reduction for implantation

6 monthsMinimum conservative therapy duration before trial

Defines UnitedHealthcare Commercial and Individual Exchange medical coverage criteria for epidural or intrathecal drug infusion trials and implantation/replacement of implanted spinal drug delivery systems (IDDS) for cancer-related pain, severe spasticity, and chronic non-malignant pain, including requirements for trials, age, documentation, and device replacement. Policy status: CURRENT. Subject: Implanted Spinal Drug Delivery Systems (Intrathecal/Epidural Drug Infusion Systems). Effective date: January 1, 2026.

Headline thresholds and stats - Implanted Spinal Drug Delivery Systems

Covered Indications3

Required trial pain reduction (for implantation)50%+

Minimum conservative therapy duration (before trial)6 months

Age threshold> 18 years

Conservative Therapy Duration (threshold)Minimum 6-month trial

Trial Pain Reduction (threshold)> 50% reduction in pain during trial

Medical Necessity Criteria

Cancer-Related Pain

Epidural or intrathecal drug infusion trial or catheter pump placement for cancer-related pain is proven and medically necessary in certain circumstances; refer to InterQual CP for medical necessity criteria.

Epidural or intrathecal drug infusion trial or catheter pump placement for cancer-related pain when InterQual CP: Procedures, Epidural or Intrathecal Catheter Placement criteria are met

Refer to InterQual criteria (link in policy)

Spasticity

Epidural or intrathecal drug infusion trial or catheter pump placement for severe spasticity is proven and medically necessary in certain circumstances; refer to InterQual CP for medical necessity criteria.

Epidural or intrathecal drug infusion trial or catheter pump placement for severe spasticity when InterQual CP: Procedures, Epidural or Intrathecal Catheter Placement criteria are met

Refer to InterQual criteria (link in policy)

Chronic Non-Malignant Pain — Trial Infusion (Screening)

Epidural or intrathecal catheter drug infusion trial for non-malignant pain is proven and medically necessary when ALL of the following are met:

ALL of the following

Chronic non-malignant pain: Chronic intractable pain of a non-malignant origin (e.g., failed back surgery syndrome, complex regional pain syndrome, neuropathic pain)
Age > 18 years> 18 years
This policy does not address individuals younger than 18 years of age.
Etiology documented: Etiology of pain is known and clearly documented
No further surgery: Further treatment or surgical intervention for underlying condition is not indicated or refused

Chronic Non-Malignant Pain — Implantation

Epidural or intrathecal catheter pump placement for non-malignant pain is proven and medically necessary when ALL of the following are met:

ALL of the following

Trial completion: Completion of drug infusion trial that met the above trial criteria
Trial response: Documentation of a > 50% reduction in pain during trial> 50% pain reduction during trial

Replacement of Device

Replacement is medically necessary when ALL of the following are met:

ALL of the following

Initial criteria met: Individual has met all criteria for initial placement
Device non-functional: Existing device is non-functional and either cannot be repaired or is no longer under warranty

Provider Actions & Documentation Requirements

Prior Authorization

Use InterQual criteria for cancer and spasticity coverage determination

For cancer-related pain and severe spasticity, the provider must refer to and document that InterQual CP: Procedures, Epidural or Intrathecal Catheter Placement criteria are met to support medical necessity. Note: UnitedHealthcare may use InterQual criteria to assist in administration of benefits.

Documentation Required

Document conservative therapy and psychosocial evaluation

Document the known etiology of pain, that further treatment or surgical intervention is not indicated or was refused, failure of conservative therapy for a minimum of 6 months, and the absence of underlying, untreated psychological or psychosocial issues that would interfere with successful pain treatment.

Minimum 6-month trial of conservative methods required
Conservative methods examples: pharmacological therapy, physical therapy, behavioral health treatment

Documentation Required

Document trial response for implantation

For permanent implantation for chronic non-malignant pain, document completion of an epidural or intrathecal drug infusion trial that met the trial screening criteria and that demonstrated significant pain relief without adverse effects.

> 50% pain reduction during trial

Documentation Required

Device replacement justification

For device replacement, document that the individual met all criteria for the initial placement and that the existing device is non-functional and either cannot be repaired or is no longer under warranty.

Applicable Codes (reference)

Applicable Procedure Codes (reference only)CPT

62320	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62321	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance
62322	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62323	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance
62324	Injection(s), including indwelling catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62325	Injection(s), including indwelling catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance
62326	Injection(s), including indwelling catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62327	Injection(s), including indwelling catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); 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

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Background, Evidence, and Definitions

Implanted drug delivery systems (catheter and pump) deliver medication intrathecally and are used for pain or spasticity. The Food and Drug Administration has approved morphine and ziconotide for intrathecal analgesia and baclofen for spasticity. Implantation of a pump is preceded by an intrathecal or epidural trial infusion to determine whether the patient exhibits an adequate response.

Hayes Health Technology Assessment: Supports intrathecal opioids for chronic noncancer pain with a large but low-quality evidence base; recommends a screening trial (commonly defined as ≥ 50% pain reduction with no adverse effects) and notes the need for larger, well-designed trials to better define long-term benefits and patient selection.

Systematic review (Duarte et al., 2022): Meta-analysis found a statistically significant reduction in pain intensity with IDDS for cancer pain (MD -3.31; 95% CI, -4.18 to -2.45) and reductions up to one month after treatment (MD -3.53); authors note limited RCT data and most evidence from nonrandomized single-center studies.

InterQual CP: Third-party criteria referenced by UnitedHealthcare for detailed medical necessity determinations for infusion trials and catheter/pump placements (referred to in policy for cancer-related pain and severe spasticity).

IDDS / IDD: Intrathecal Drug Delivery System; implanted catheter and pump delivering medication into the intrathecal space.

Policy Summary

PayerColorado Rocky Mountain Health Plans | UnitedHealthcare Commercial and Individual Exchange

PolicyImplanted Spinal Drug Delivery Systems (Intrathecal/Epidural Drug Infusion Systems)

Policy CodePolicy 2026T0626M

Change TypeTemplate Update

Effective DateJan 1, 2026

Next Review Date

On This Page

OpenPayer

Implanted Spinal Drug Delivery Systems (Intrathecal/Epidural Drug Infusion Systems)

Coverage Summary

Medical Necessity Criteria

Provider Actions & Documentation Requirements

Applicable Codes (reference)

Background, Evidence, and Definitions

Revision History