CurrentHealth NetPolicy CP.MP.173

Implantable Intrathecal or Epidural Pain Pump

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Defines medical necessity criteria, contraindications, and coding references for preliminary trial and permanent implantation of intrathecal or epidural drug delivery systems for chronic malignant and nonmalignant pain for Health Net members.

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CurrentHealth NetPolicy CP.MP.173

Implantable Intrathecal or Epidural Pain Pump

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Policy Summary

PayerHealth Net

PolicyImplantable Intrathecal or Epidural Pain Pump

Policy CodePolicy CP.MP.173

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document a preliminary intrathecal or epidural trial demonstrating ≥50% pain reduction (with required documentation of indications, conservative treatment failures, and contraindication assessment).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥50%required pain reduction in trial to proceed to permanent implant

>3 mominimum life expectancy for malignant and nonmalignant indications

listedprocedure and device codes provided

listedabsolute contraindications listed

21+references cited (selected literature/guidelines)

Centenepolicy owner

Medical Necessity and Contraindications

Preliminary Trial Criteria

Preliminary trial is medically necessary when ALL of the following are met

Indication: Request is for either: 1) Chronic intractable pain of malignant origin when all of the following are met: inadequate response to, or intolerable side effects from, noninvasive methods of pain control such as systemic opioids; life expectancy > three months; and no evidence of epidural metastatic lesion(s) or tumor encroachment of the thecal sac by imaging; OR 2) Chronic intractable pain of nonmalignant origin when all of the following are met: pathology for the pain has been identified; life expectancy > three months; failure or inability to tolerate other conservative treatment methods (including 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; further surgical intervention or other treatment is not indicated or likely to be effective; systemic opioids have been weaned by at least 50% prior to the trial; and opioid-induced hyperalgesia has been ruled out as a possible cause of the chronic pain symptoms.all

Preliminary trial may be epidural or intrathecal.

Permanent Implantation Criteria

Permanent implantation is medically necessary when ALL of the following are met (in addition to preliminary trial criteria)

Malignant indication: Preliminary trial criteria have been met AND the trial provided ≥ 50% reduction in pain with minimal side effects; 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; and no known allergy or hypersensitivity to the drug being used.all

Trial requirement for malignant origin may be reviewed on a case-by-case basis for advanced disease or limited survival.

Nonmalignant indication: Preliminary trial criteria have been met AND the preliminary trial provided ≥ 50% reduction in pain and increase in function with minimal side effects; 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 implantation and fixation of a catheter for drug delivery; and continued active participation in behavioral health or psychological treatment modalities.all

Also requires meeting preliminary trial criteria.

Contraindications

Contraindications (presence of any of the following excludes trial or implantation)

Absolute contraindications: 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.any

These are listed as absolute contraindications.

Intrathecal drug delivery systems provide targeted, long-term analgesia for select patients with recalcitrant pain after failure of conservative and surgical treatments. Their use for chronic noncancer pain is controversial and is generally reserved as a last resort when other options have failed. A preliminary intrathecal or epidural trial infusion is performed prior to permanent implantation to assess response; the trial typically requires a predefined improvement in pain (usually ≥ 50%) without intolerable adverse effects. If a successful trial occurs, the catheter and pump may be implanted with fluoroscopic guidance and standard surgical technique.

Coverage under this clinical policy is provided as a guide to medical necessity to assist in coverage decisions and benefit administration. Actual coverage is determined by the member's governing coverage documents (e.g., evidence of coverage, certificate of coverage, or policy), and is subject to all applicable terms, conditions, exclusions and limitations of those documents as well as state and federal requirements. Providers should follow the Health Plan's administrative policies and the applicable regulatory guidance when seeking authorization or submitting claims.

The policy does not issue an across-the-board "not medically necessary" determination for intrathecal therapy in noncancer pain. Rather, it acknowledges a limited evidence base for nonmalignant pain and manages utilization through specific, stringent medical necessity criteria, required trials, contraindications, and documentation standards instead of a blanket NMN exclusion.

Prior Conservative Therapies and Failure Requirements

documented failure/intolerance of conservative therapies

Documented failure or intolerance of conservative therapies is required for nonmalignant indications

Conservative therapy requirement: For chronic intractable nonmalignant pain, there must be documented failure of, 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 treatments.all

Documentation of prior conservative treatments and reasons for failure or intolerance should be provided.

(conservative treatment nodes)

Conservative care prerequisites (required prior to a trial for nonmalignant pain)

Required conservative modalities: Attempted and documented conservative treatments including: 1) systemic pharmacotherapy appropriate to the pain condition; 2) structured physical therapy; 3) behavioral health interventions for pain management; and 4) appropriate nonsurgical treatments (e.g., indicated injections, rehabilitation).

Procedure, Supply, and Drug Codes

Covered CPT CodesCPTCovered

62320	Injection(s), of diagnostic or therapeutic substance(s) (eg, 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) (eg, 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 (ie, fluoroscopy or CT).
62322	Injection(s), of diagnostic or therapeutic substance(s) (eg, 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) (eg, 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 (ie, fluoroscopy or CT).
62326	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, 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) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT).
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.
62355	Removal of previously implanted intrathecal or epidural catheter.
62360	Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir.

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Covered HCPCS / Supply / Drug CodesHCPCSCovered

A4300	Implantable access catheter, (e.g., venous, arterial, epidural subarachnoid, or peritoneal, etc.) external access.
A4301	Implantable access total catheter, port/reservoir (e.g., venous, arterial, epidural, subarachnoid, peritoneal, etc.).
E0782	Infusion pump, implantable, nonprogrammable (includes all components, e.g., pump, catheter, connectors, etc.).
E0783	Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.).
E0785	Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement.
E0786	Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter).
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).

inv-09: Trial pain reduction threshold — >= 50%

Required trial pain reductionPreliminary or percutaneous intrathecal/epidural trial must demonstrate ≥ 50% reduction in pain with minimal side effects to proceed to permanent implantation.

Trial purposeDetermine whether patient exhibits an adequate response (predefined improvement in pain, usually ≥ 50%) without intolerable adverse effects prior to implanting the pump.

Applies toBoth malignant and nonmalignant indications as part of preliminary trial and as a specific requirement for permanent implantation criteria.

inv-10: Life expectancy — > 3 months

Minimum life expectancyLife expectancy greater than three months is required for both malignant and nonmalignant indications.

Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior authorization required for listed CPT/HCPCS codes

Submit prior authorization for all listed CPT and HCPCS codes related to trialing, implantation, removal, and device supply before performing the service; requests will be reviewed against the policy's medical necessity criteria.

Covered CPT codes include: 62320–62327, 62350–62370 (see policy coding list).
Covered HCPCS/supply/drug codes include: A4300, A4301, E0782, E0783, E0785, E0786, C1772, C1755, J2274, S0093.

Prior Authorization

Use policy as medical necessity guide for prior authorization

Follow this clinical policy as a medical necessity guide when requesting prior authorization; administrative prior authorization expectations must also align with the Health Plan's member coverage documents and administrative policies.

This policy is a guide to medical necessity and does not guarantee payment; verify member-specific coverage, terms, conditions, exclusions and limitations.
Prior authorization processes should follow applicable Health Plan administrative policies and the member's coverage documents.

Pre-implantation Evaluation and Procedural Guidance

Billing Rule

Perform imaging for evaluation and fluoroscopic-guided catheter placement

Obtain appropriate pre-implantation imaging to confirm no epidural metastatic lesions or tumor encroachment for malignant indications and to guide catheter placement; catheter placement is typically performed under fluoroscopic guidance.

Imaging must document absence of epidural metastatic lesions or thecal sac encroachment for malignant cases.
Use fluoroscopic guidance for catheter tip positioning during implantation.

Note

Apply referenced trialing/implantation recommendations in procedural planning

Follow cited intrathecal trialing and implantation recommendations (including the Polyanalgesic Consensus Conference) for procedural conduct and trial methodology when planning trials and permanent implantation.

Clinical Context

Intrathecal and epidural implantable pumps consist of a catheter and a constant-flow or programmable pump that deliver medications (for example, opioids, ziconotide, or clonidine) directly into the intrathecal or epidural space to provide targeted analgesia. These systems are most commonly used for cancer-related pain. Implantation follows a successful trial infusion demonstrating an adequate predefined reduction in pain (usually ≥ 50%), and catheter placement is typically guided by fluoroscopy with the pump placed in a subcutaneous abdominal pocket.

Key Terms

inv-20: Intrathecal drug delivery system — implantable pump and catheter that delivers medication directly into the spinal fluid; can be programmable or nonprogrammable for continuous or variable infusion

DefinitionAn intrathecal drug delivery system is an implantable pump and catheter that delivers medication directly into the spinal fluid.

Pump typesThe pump can be programmable or nonprogrammable and may provide continuous (constant-flow) or variable infusion rates.

PurposeProvides targeted, long-term analgesia for select patients with intractable pain after failure of conservative and surgical treatments.

inv-21: Intrathecal drug delivery system / implantable pump — An implanted pump system that delivers opioids or other agents into the intrathecal or epidural space for management of chronic cancer or...

System descriptionAn implanted pump system delivers opioids or other agents into the intrathecal or epidural space for management of chronic cancer or noncancer pain as described in reviews and consensus recommendations.

Policy Summary

PayerHealth Net

PolicyImplantable Intrathecal or Epidural Pain Pump

Policy CodePolicy CP.MP.173

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Evidence of compliance with and an adequate trial of these modalities must be documented.

Psychosocial assessment: Psychological evaluation must confirm that a major psychiatric condition is not the primary contributor to chronic pain; continued active participation in behavioral health or psychological treatment modalities is expected for those proceeding to permanent implantation.all

References include consensus guidance on psychosocial interventions and trialing (see policy references).

Malignant indication note

For chronic intractable malignant pain, life expectancy > three months is required as part of preliminary trial criteria.

Nonmalignant indication noteFor chronic intractable nonmalignant pain, life expectancy > three months is required and is part of preliminary trial criteria before trialing an implantable system.

Step Therapy

Documented trial showing ≥ 50% pain reduction required prior to implantation

Perform and document a preliminary epidural or intrathecal trial infusion demonstrating adequate response—typically defined as a predefined improvement in pain (usually ≥ 50%) without intolerable adverse effects—before permanent implantation for most patients.

Trial must show ≥ 50% reduction in pain (and increase in function for nonmalignant indications) with minimal side effects.
Document trial details (method, results, side effects) in the prior authorization/medical record.

Note

Follow PACC and cited guidance for trialing/staged approaches

Reference Polyanalgesic Consensus Conference (PACC) recommendations and cited consensus/guideline literature when planning and documenting trialing and staged approaches to intrathecal therapy.

The PACC trialing recommendations (Deer et al., Neuromodulation 2017) inform procedural trial approaches and staged therapy decisions.
Include citation or note of guideline-aligned methods in the documentation when applicable.

Documentation Required

Submit required clinical documentation with authorization

Include comprehensive documentation with the prior authorization request and medical record: indication, conservative treatment history and failures, psychological evaluation, life expectancy, and full trial details.

Indication: malignant or nonmalignant chronic intractable pain and imaging for malignant cases (no epidural metastatic lesions or tumor encroachment).
Conservative treatments tried and failed (systemic pharmacotherapy, physical therapy, behavioral health, appropriate nonsurgical treatments).
Psychological evaluation confirming mental health is not a major contributor; life expectancy > three months.
Trial details showing ≥ 50% pain reduction, minimal side effects, and plan to wean systemic opioids when indicated.

Documentation Required

Align documentation with coverage and regulatory requirements

Ensure documentation and requests comply with applicable coverage documents and state/federal requirements; review Medicare NCDs/LCDs and the state Medicaid manual when those programs apply.

If state Medicaid provisions conflict with this policy, the state Medicaid provisions take precedence—refer to the state Medicaid manual.
For Medicare members, review applicable NCDs, LCDs, and Medicare Coverage Articles prior to applying these criteria.

Denial Risk

Missing trial data or contraindications may trigger denial

Requests will be denied if required trial evidence or contraindication screening is missing—specifically, absence of a trial showing ≥ 50% pain reduction or presence of listed absolute contraindications may lead to denial.

Absolute contraindications include: active systemic infection, active infection at the implantation site, known allergies to implant materials, active alcohol or drug abuse (including opioid addiction and IV drug use), and diagnosis of dementia or psychosis.
Include explicit trial outcome data and contraindication screening in the submission to avoid denial.

Denial Risk

Coverage or regulatory conflicts can cause denial

Coverage decisions are subject to the member's coverage documents and applicable law; conflicts with state Medicaid provisions or Medicare NCD/LCDs may alter coverage and can result in denial.

Verify member-specific terms, exclusions and limitations before proceeding with authorization.
When discrepancies exist, follow state Medicaid manual for Medicaid members and review Medicare NCDs/LCDs for Medicare members.

Use referenced consensus and guideline literature to inform trial techniques, interpretation of results, and staged approaches to therapy.

Medication examplesMedications used include opioids (e.g., morphine) and combinations with local anesthetics or other agents (e.g., ziconotide, clonidine).

Evidence and guidanceClinical uses and placement are discussed in cited health technology assessments, reviews, and consensus statements referenced in the policy.