CurrentevicorePolicy CMM-210

Implantable Intrathecal Drug Delivery Systems

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Defines medical necessity and coverage criteria for use of implantable intrathecal or epidural drug delivery systems (pain/baclofen pumps) for non-malignant chronic intractable pain and severe refractory spasticity/dystonia, and guidance for trials and exclusions; applies to Cigna-administered health benefit plans managed by eviCore.

Policy Summary

Payerevicore

PolicyImplantable Intrathecal Drug Delivery Systems

Policy CodePolicy CMM-210

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

Key ActionDocument failure of specified conservative therapies (including ≥6 months of active rehabilitative exercise and ≥6 months of fixed‑schedule systemic analgesics for non‑malignant pain) and evidence of opioid reduction prior to trial.

SourceLink

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CurrentevicorePolicy CMM-210

Implantable Intrathecal Drug Delivery Systems

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Policy Summary

Payerevicore

PolicyImplantable Intrathecal Drug Delivery Systems

Policy CodePolicy CMM-210

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsMinimum rehab + fixed‑schedule duration

50%Required opioid reduction prior to trial

50%Pain reduction threshold for permanent implant

2‑pointSpasticity score improvement threshold

3Major indication groups

ListExcluded injectates

Coverage Criteria

inv-01: Trial (non-malignant chronic intractable pain) — percutaneous intrathecal or epidural trial ALL criteria

Covered when ALL of the following are met for a percutaneous intrathecal or epidural trial:

Documented pathology: There is documented pathology of non-malignant, chronic intractable pain (e.g., failed back surgery syndrome, post-herpetic neuralgia, complex regional pain syndrome).

Conservative treatment failure: Failure of provider-directed non-invasive pain management that includes BOTH active rehabilitative exercise for at least six (6) months AND a fixed schedule dosing of opioids or other analgesics for at least six (6) months, unless contraindicated.6 months

Both elements required unless contraindicated

No further surgical/treatment options: Further surgical intervention or other treatment is not indicated or likely to be effective.

Behavioral health assessment: An attestation from a primary care physician, neurologist, physiatrist, psychiatrist, psychologist, or other licensed behavioral and/or medical health care provider (face-to-face or virtual assessment permitted) reveals no evidence of an inadequately controlled mental and/or behavioral health condition that is a major contributor to chronic pain.

Face-to-face or virtual assessment permitted

Opioid reduction: Individual agrees to a 50% reduction in systemic opioids prior to undergoing an intrathecal opioid trial.50%

inv-02: Trial — Non-Malignant, Chronic Intractable Pain — ALL criteria for trial medical necessity

A trial with a percutaneous intrathecal or epidural drug delivery system is considered medically necessary when ALL of the following are met:

Non-malignant pain trial criteria: There is documented pathology of non-malignant, chronic intractable pain (e.g., failed back surgery syndrome, post-herpetic neuralgia, complex regional pain syndrome).

Conservative therapy failure: Failure of provider-directed non-invasive pain management including BOTH active rehabilitative exercise for at least six (6) months AND a fixed schedule dosing of opioids or other analgesics for at least six (6) months, unless contraindicated.6 months

Both elements required unless contraindicated

No further effective surgery: Further surgical intervention or other treatment is not indicated or likely to be effective.

inv-03: Permanent — Non-Malignant, Chronic Intractable Pain — BOTH criteria required for permanent implantation

Permanent implantation is considered medically necessary when BOTH of the following criteria have been met:

Prior trial: The above criteria have been met for a trial of intrathecal or epidural opioid administration.

Trial outcome: The trial resulted in BOTH documented pain relief of >50% for eight (8) hours AND documented concomitant increase in function.>50% for 8 hours

inv-04: Trial and Permanent — Severe Refractory Spasticity/Chronic Intractable Dystonia — trial EITHER scenario; permanent ALL trial criteria

Trial is medically necessary when EITHER clinical scenario below is met; permanent implantation is medically necessary when ALL trial criteria are met and the trial resulted in a beneficial clinical response as defined:

Spasticity trial prerequisites: Documentation that the individual is unresponsive to, cannot tolerate, or has a contraindication to a trial of BOTH oral antispasmodic drugs (e.g., baclofen) for at least six (6) weeks AND physical therapy for at least six (6) weeks.6 weeks

Baseline scores: Individual has BOTH a baseline average Ashworth Score >= 3 or Modified Ashworth Score >= 2 AND a Penn Spasm Frequency Score >= 2.Ashworth >=3 or Modified Ashworth >=2; Penn >=2

Permanent trial response: Trial resulted in EITHER at least a 2-point reduction in the Ashworth or Modified Ashworth Score for four (4) hours following an intrathecal baclofen bolus OR at least a 2-point reduction in the Penn Spasm Frequency Score for four (4) hours.

inv-05: Trial and Permanent — Cancer-Related Pain — trial criteria and permanent implantation conditions

A trial is considered medically necessary when there is failure, intolerance, or contraindication to non-invasive methods of pain control, including systemic opioids.

Trial for cancer pain: Failure, intolerance, or contraindication to non-invasive pain control including systemic opioids justifies a percutaneous intrathecal or epidural trial.

Permanent implantation for cancer pain: Permanent implantation is medically necessary when trial criteria are met and the trial resulted in documented pain relief of at least 50%.>=50%

Exception to trial for cancer: A trial is not required in the presence of advanced disease with limited survival and high procedural risk.

exceptional scenario

inv-06: Replacement — medically necessary replacement conditions listed

Replacement of an implanted intrathecal or epidural drug delivery system is considered medically necessary for ANY of the following:

Battery end-of-life: Existing device is documented to be nearing end of battery life.

Non-repairable device: Existing device will no longer be functional and cannot be repaired.

Built-in failure notification: A built-in device component provides notification of impending failure.

The guideline explicitly excludes use of implantable intrathecal or epidural drug delivery systems with certain injectates. Uses with Spinraza, chemotherapy, neurolytic substances, antibiotics, antivirals, and biologics (for example, platelet-rich plasma, stem cells, amniotic fluid) are out of scope and not covered under this policy.

These coverage criteria apply to intrathecal or epidural drug delivery systems for therapeutic indications such as non-malignant chronic intractable pain and severe refractory spasticity/dystonia, and are not applicable to use for obstetrical or surgical epidural anesthesia.

Placement of an implantable intrathecal or epidural drug delivery system (whether trial, permanent implant, or replacement) that does not meet the requirements set forth in the Definitions, General Guidelines, and Indications sections is considered not medically necessary and may be denied.

Replacement of an implanted infusion pump or related components is considered not medically necessary when the existing device and/or components remain functional. Documentation supporting replacement should demonstrate end of battery life, irreparable dysfunction, or a built-in notification of impending failure to meet the policy's replacement criteria.

The CPT code descriptors for injection and catheter placement procedures explicitly state that those codes do not include use of neurolytic substances. Claims and documentation should reflect that neurolytic agents are excluded when submitting codes such as 62325–62327.

Guideline criteria and the coverage framework in this policy do not apply to obstetrical or surgical epidural anesthesia; such uses fall outside the scope of this coverage policy and should be evaluated under the applicable anesthesia or procedural benefit rules.

Any implantable intrathecal or epidural drug delivery system placed without meeting the specified criteria in this document (Definitions, General Guidelines, and Indications) is considered not medically necessary and may be denied.

Replacement of an infusion pump is not medically necessary when the existing device and/or components remain functional. Permissible reasons for replacement under the policy include documented imminent battery end-of-life, irreparable device failure, or an internal notification indicating impending failure.

Conservative Treatment Requirements

inv-47: Both elements required prior to trial — minimum durations

Both elements below must be documented and attempted prior to a trial:

Active rehabilitative exercise has been provided and documented for at least six (6) months.6 months

Fixed-schedule systemic analgesics: A fixed schedule dosing regimen of systemic opioids or other analgesics has been provided and documented for at least six (6) months.6 months

Both elements required prior to trial unless contraindicated

inv-48: Rehabilitative exercise + fixed-schedule systemic analgesics — >= 6 months required

For non-malignant chronic intractable pain, both conservative therapies must be attempted for at least six (6) months each:

Coding

Codes listed in policyCPT

62320	Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62321	Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT).
62322	Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
62323	Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT).
62324	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62325	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT).
62326	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
62327	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT).

Injection and catheter placement CPT codesCPT

62325	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT)
62326	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62327	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance

Implantation and device CPT codesCPT

62350	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy
62351	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy
62360	Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir
62361	Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump
62362	Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump with or without programming

Opioid reduction requirement — 50% prior to intrathecal opioid trial

RequirementIndividual agrees to a 50% reduction in systemic opioids prior to undergoing an intrathecal opioid trial.

Applies toPercutaneous intrathecal or epidural opioid trial for non-malignant, chronic intractable pain.

DocumentationAttestation and clinical documentation must show the agreed opioid reduction prior to trial initiation.

Conservative therapy duration — non-malignant pain (trial prerequisites)

DurationActive rehabilitative exercise for at least 6 months.

Duration

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization and medical necessity documentation required for trial

A percutaneous intrathecal or epidural trial is considered medically necessary only when the policy's trial criteria are met and supporting documentation is submitted for prior authorization review; documentation must include the clinical history, failed conservative therapies, behavioral/mental health attestation, and evidence of opioid reduction as specified in the policy.

Documented pathology of non-malignant, chronic intractable pain (see examples in policy).
Failure of provider-directed non-invasive management including BOTH active rehabilitative exercise ≥6 months AND fixed-schedule opioids/analgesics ≥6 months, unless contraindicated.
Attestation by an appropriate clinician that inadequately controlled behavioral/mental health conditions are not major contributors.
Individual agrees to a 50% reduction in systemic opioids prior to an intrathecal opioid trial.

Note

Verify plan-specific prior authorization for listed CPT codes

Imaging Requirements

Note

Imaging guidance for trial/implant not specified here

Imaging requirements for trials/implants are not specifically detailed in the trial criteria section; refer to CPT descriptors and coding section for imaging guidance requirements.

Billing Rule

Use fluoroscopy/CT when CPT code indicates imaging guidance

For percutaneous intrathecal or epidural injections and catheter placements, use fluoroscopy or CT when the CPT code descriptor specifies 'with imaging guidance (i.e., fluoroscopy or CT)'.

Codes specifying imaging guidance include descriptors that state use of fluoroscopy or CT.

Billing Rule

Definitions

Implantable Intrathecal Drug Delivery System — definition & purpose

DefinitionA device used for continuous infusion of a drug directly into the cerebrospinal fluid via a catheter placed in the intrathecal or epidural space; pump reservoir is placed subcutaneously in the abdomen.

PurposeDelivers medication for long-term management to facilitate restoration of function (not solely for pain reduction).

Trial optionsAn intrathecal drug delivery trial may be performed by single intrathecal bolus injection or intrathecal catheter infusion.

Ashworth/MAS/PSFS — scales and grading

Ashworth Scale (grading)0=no increase in tone; 1=slight increase with catch; 2=more marked increase but limb easily flexed; 3=considerable increase, passive movement difficult; 4=limb rigid.

Penn Spasm Frequency Score (grading)

Background

An implantable intrathecal drug delivery system delivers medication directly into the cerebrospinal fluid via a catheter placed in the intrathecal or epidural space. The device includes a subcutaneous reservoir or pump implanted (typically in the abdomen) that provides continuous infusion, with the intended purpose of managing severe pain or spasticity and facilitating functional improvement rather than solely short-term symptom relief. Trials may be performed as a single intrathecal bolus or via catheter infusion to assess response prior to permanent implantation.

Not Covered / Exclusions

Uses and injectates outside the policy scope are not covered. Specifically, intrathecal or epidural delivery of Spinraza, chemotherapy, neurolytic substances, antibiotics, antivirals, or biologic injectates (for example, PRP, stem cells, amniotic fluid) are excluded. Additionally, the CPT descriptors for injection/catheter placement codes clarify that they exclude neurolytic substances, reinforcing that such agents are not covered under these procedure codes.

Policy Summary

Payerevicore

PolicyImplantable Intrathecal Drug Delivery Systems

Policy CodePolicy CMM-210

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

SourceLink

On This Page

Behavioral health assessment:

Attestation from a primary care physician, neurologist, physiatrist, psychiatrist, psychologist, or other licensed behavioral/medical provider (face-to-face or virtual) indicates no inadequately controlled mental/behavioral health condition contributing to pain.

Face-to-face or virtual assessment permitted

Opioid reduction agreement: Individual agrees to a 50% reduction in systemic opioids prior to undergoing an intrathecal opioid trial.50%

2-point reduction for 4 hours

Rehabilitative exercise duration: Active rehabilitative exercise must be provided and documented for a minimum of six (6) months.6 months

Fixed-schedule analgesics duration: Fixed-schedule dosing of opioids or other systemic analgesics must be provided and documented for a minimum of six (6) months.6 months

inv-49: Oral antispasmodics + physical therapy — >= 6 weeks required for spasticity/dystonia

For severe refractory spasticity or chronic intractable dystonia, both conservative therapies must be attempted for at least six (6) weeks each unless contraindicated:

Oral antispasmodics duration: Trial of oral antispasmodic drugs (e.g., baclofen) for at least six (6) weeks, or documentation of intolerance/contraindication.6 weeks

Physical therapy duration: Trial of physical therapy for at least six (6) weeks, or documentation of intolerance/contraindication.6 weeks

Fixed-schedule dosing of opioids or other systemic analgesics for at least 6 months.

ScopeBoth elements must be attempted (unless contraindicated) prior to a percutaneous intrathecal or epidural trial for non-malignant chronic intractable pain.

Pain reduction threshold for permanent implantation

Threshold>= 50% documented pain relief during trial (documented pain relief of >50% for eight hours for non-malignant pain).

Additional requirementDocumented concomitant increase in function following the trial for permanent implantation (non-malignant pain).

Cancer-relatedPermanent implantation for cancer-related pain requires documented pain relief of at least 50% (trial exception may apply in advanced disease).

Spasticity/dystonia trial response — required clinical improvement

Response magnitudeAt least a 2-point reduction in the Ashworth Score or Modified Ashworth Score for four (4) hours after an intrathecal baclofen bolus.

Alternate responseAt least a 2-point reduction in the Penn Spasm Frequency Score for four (4) hours following intrathecal baclofen bolus.

Assessment toolsUse Ashworth/MAS scales and Penn Spasm Frequency Score as defined in policy to grade spasticity and spasm frequency.

Conservative therapy duration (non-malignant pain)

Rehabilitation>= 6 months of active rehabilitative exercise required prior to trial.

Systemic analgesics>= 6 months of fixed-schedule systemic analgesics (opioids or other analgesics) required prior to trial.

ConditionApplies to non-malignant, chronic intractable pain trials unless contraindicated.

Conservative therapy duration (spasticity/dystonia)

Oral antispasmodics>= 6 weeks trial of oral antispasmodic drugs (e.g., baclofen) or documentation of intolerance/contraindication.

Physical therapy>= 6 weeks of physical therapy or documentation of intolerance/contraindication.

Baseline scoresBaseline Ashworth (or Modified Ashworth) and Penn Spasm Frequency scores must be documented prior to trial.

Inclusion of CPT codes in this policy does not by itself indicate they require prior authorization; providers must check the member's applicable health plan/Coverage documents to confirm plan-specific prior authorization or management requirements.

Codes listed (e.g., 62320–62327, 62350–62362) are for reference; verify with the applicable health plan whether prior authorization is required.
Prior authorization of a code is not a guarantee of payment; refer to the Certificate of Coverage/Evidence of Coverage.

Prior Authorization

Prior authorization required for implantation/revision/replacement

Prior authorization applies to implantation, revision, or replacement of tunneled intrathecal/epidural catheters and intrathecal/epidural drug infusion devices; ensure device type and whether a laminectomy was performed are documented for the request.

Applicable codes include 62350–62362 for implantation/revision/replacement procedures.
Document whether laminectomy was performed (relevant to 62350 vs 62351) and the device type (reservoir, nonprogrammable pump, programmable pump).

Step Therapy

Demonstrate failure of conservative non-invasive therapies before trial

Providers must demonstrate failure of non-invasive pain management prior to trial; for non-malignant pain this requires BOTH active rehabilitative exercise and fixed-schedule systemic analgesics for the durations specified in the policy.

Active rehabilitative exercise for at least six (6) months.
Fixed schedule dosing of opioids or other analgesics for at least six (6) months (unless contraindicated).

Step Therapy

Document required conservative therapy trials (non-malignant pain; spasticity/dystonia)

Required conservative therapy prerequisites must be documented before a trial: for non-malignant pain, ≥6 months each of active rehab and fixed-schedule systemic analgesics; for spasticity/dystonia, ≥6 weeks of oral antispasmodics and ≥6 weeks of physical therapy (or documentation of intolerance/contraindication).

Non-malignant pain: active rehabilitative exercise ≥6 months AND fixed-schedule systemic analgesics ≥6 months.
Spasticity/dystonia: trial, intolerance, or contraindication to oral antispasmodics for ≥6 weeks AND physical therapy for ≥6 weeks; include baseline Ashworth and Penn scores.

Note

Step therapy not specified in this section — follow plan rules

This policy does not specify additional step therapy protocols beyond the conservative therapy prerequisites; follow plan-level step therapy rules if separately defined by the health plan.

Documentation Required

Clinical documentation required for trial prior authorization

Submit clinical documentation with the trial prior authorization: pathology, documentation of failed non-invasive management (including the required durations of active rehab and fixed-schedule analgesics), behavioral health attestation, and evidence of the required opioid reduction.

Diagnosis and clinical history documenting non-malignant chronic intractable pain.
Records showing ≥6 months active rehabilitative exercise and ≥6 months fixed-schedule systemic analgesics (or documented contraindication).
Attestation from an appropriate licensed clinician regarding behavioral/mental health.
Documentation showing individual agrees to a 50% reduction in systemic opioids prior to intrathecal opioid trial.

Documentation Required

Documentation specifics for non-malignant pain trial

For non-malignant pain trials, include documented pathology, failure of the required conservative therapies (≥6 months each), and the clinician attestation about behavioral/mental health as part of the prior authorization package.

Diagnosis examples provided in policy (e.g., failed back surgery syndrome, post-herpetic neuralgia, complex regional pain syndrome).
Explicit documentation of the two required conservative therapy elements and durations.

Documentation Required

Documentation requirements for spasticity/dystonia trial

For spasticity/dystonia trials, document failure, intolerance, or contraindication to BOTH oral antispasmodics (≥6 weeks) and physical therapy (≥6 weeks), and include baseline Ashworth and Penn Spasm Frequency scores.

Record of oral antispasmodic trial (e.g., baclofen) for at least six (6) weeks or documented intolerance/contraindication.
Documentation of at least six (6) weeks of physical therapy or reason it was not possible.
Baseline average Ashworth Score and Penn Spasm Frequency Score.

Documentation Required

Document trial outcomes for permanent implantation

For permanent implantation requests, include trial results that meet the policy's response thresholds: for non-malignant pain, documented >50% pain relief for eight hours plus increased function; for spasticity, the specified score reductions sustained for four hours.

Non-malignant pain: trial documentation showing >50% pain relief for eight (8) hours and documented functional improvement.
Spasticity/dystonia: trial showing ≥2-point reduction in Ashworth/Modified Ashworth or Penn score for four (4) hours after intrathecal bolus.

Documentation Required

Documentation required for replacement requests

For replacement requests, document that the existing device is nearing end of battery life, is irreparably dysfunctional, or that a built-in device component has notified of impending failure; absence of such documentation risks denial.

Evidence of battery depletion or manufacturer notification.
Documentation of attempted repairs and justification that device cannot be repaired.
Built-in failure notification records, if applicable.

Billing Rule

Ensure procedure documentation aligns with selected CPT code descriptors

Operative reports and submitted claims must match the exact CPT code descriptions in the policy (for example, indicate imaging guidance if performed; specify catheter site and device type) to avoid coding-related denials.

If imaging guidance (fluoroscopy/CT) was used, select the CPT code that includes imaging guidance (e.g., 62325, 62327) and document imaging in the operative note.
For catheter implantation, document anatomical site (cervical/thoracic vs lumbar/sacral) to align with code descriptors.
For device implantation/replacement, document device type (subcutaneous reservoir, nonprogrammable pump, programmable pump) and whether programming/preparation was performed (relevant to 62360–62362).

Note

Resolve coverage conflicts per the applicable benefit plan

Coverage determinations are governed by the terms of the member's applicable benefit plan document and applicable laws; if a benefit plan contains exclusions or differing terms, those plan provisions supersede the policy and may trigger denial.

Refer to the member's Certificate of Coverage/Evidence of Coverage for plan-specific exclusions and requirements.
In case of conflict between this policy and the benefit plan document, the benefit plan document controls.

Denial Risk

Denial risk if placement performed without meeting criteria

Placement of a trial, permanent implant, or replacement without meeting the policy's Definitions, General Guidelines, and Indications is considered not medically necessary and may be denied.

Ensure all indication criteria and general guideline requirements are met and documented prior to the procedure.
Failure to provide required documentation or to meet criteria is a common basis for claim denial.

Denial Risk

Denial risk for unnecessary replacement when device remains functional

Replacement requests lacking evidence that the existing device or components are nonfunctional or near end of battery life risk denial because replacement of a functioning device is considered not medically necessary.

Do not request replacement solely for convenience; include device failure or end-of-life documentation.
Claims for replacement when original device remains functional are explicitly listed as not medically necessary.

Denial Risk

Risk of denial for coding/documentation mismatch

Claims for intrathecal/epidural catheter placement and device implantation/replacement may be denied if the CPT code submitted does not match the procedure performed or if operative documentation does not support the selected code.

Incorrect selection between codes specifying imaging guidance vs without guidance may cause denial.
Mismatch between documented catheter site, device type, or laminectomy status and the CPT code can result in claim rejection.

Document imaging use for CPT 62325–62327 per code descriptors

For CPT codes 62325, 62326, and 62327, imaging guidance is conditional per the CPT code description—document whether imaging (fluoroscopy/CT) was used because some codes specify 'with imaging guidance' and others 'without imaging guidance'.

62325 and 62327 descriptions specify 'with imaging guidance (i.e., fluoroscopy or CT)'.
62326 is described 'without imaging guidance'—ensure documentation reflects the technique used.

0=no spasm; 1=mild spasms induced by stimulation; 2=infrequent full spasms (< once/hr); 3=spasms > once/hr; 4=spasms >10 times/hr.

UseThese scales assess spasticity and spasm frequency and are used to document baseline and trial responses for spasticity/dystonia indications.

Ashworth and Penn scores — baseline requirements

Required baselineDocument baseline average Ashworth Score >=3 or Modified Ashworth Score >=2 and Penn Spasm Frequency Score >=2 prior to trial.

PurposeBaseline motor/spasticity scales are required to assess eligibility and measure trial response in spasticity/dystonia.

DocumentationBaseline scores must be recorded in the clinical record and used to compare post-trial improvements (e.g., 2-point reductions).

Imaging guidance — fluoroscopy or CT per CPT descriptors

DefinitionUse of fluoroscopy or CT during injection or catheter placement when CPT code descriptor specifies 'with imaging guidance'.

ApplicabilityImaging guidance is required or conditional per CPT code (e.g., 62325, 62327 indicate with imaging guidance; 62326 describes without imaging guidance).

DocumentationOperative documentation must specify whether imaging guidance (fluoroscopy/CT) was used to align with submitted CPT code.

Programmable pump — definition and CPT reference

DefinitionAn implanted intrathecal or epidural drug infusion device that allows programming of infusion parameters.

CPT referenceDescribed in CPT code 62362: 'Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump with or without programming.'

UseProgrammable pumps permit adjustment of infusion parameters and are coded specifically under 62362 for implantation or replacement.

Subcutaneous reservoir — definition and CPT reference

DefinitionAn implanted subcutaneous reservoir device for intrathecal or epidural drug infusion.

CPT referenceReferenced in CPT code 62360: 'Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir.'

UseUsed as an implanted reservoir for long-term medication administration and coded specifically under 62360 for implantation or replacement.