Anthem Blue Cross Connecticut CG-SURG-79 Implantable Infusion Pumps Form

This document addresses the use of implantable infusion pumps, intended to provide long-term, continuous, or intermittent drug infusion. The document does not address implantable reservoirs or implantable infusion systems without a pump.

Medically Necessary:

Implantable infusion pumps are considered medically necessary when used to deliver drugs for the treatment of:

1. Primary liver cancer (intrahepatic artery injection of chemotherapeutic agents); or
2. Metastatic colorectal cancer where metastases are limited to the liver (intrahepatic artery injection of chemotherapeutic agents); or
3. Severe, refractory spasticity of cerebral or spinal cord origin in individuals who are unresponsive to or cannot tolerate oral baclofen (Lioresal^®) therapy (intrathecal injection of baclofen); or
4. Pulmonary arterial hypertension for individuals that have previously been receiving the drug treprostinil (Remodulin^®) via an external infusion pump; or
5. Severe, chronic, intractable pain when a successful trial of opioid or nonopioid analgesics by the same route of administration as the planned treatment (for example, intravenous, intrathecal, or epidural injection).

Note: A successful trial is defined as greater than 50% reduction in pain.

Note: When an implantable/intrathecal infusion pump is determined to be medically necessary, the supplies necessary for the proper use of the pump are considered medically necessary.

Replacement of an implantable/intrathecal infusion pump (which may also involve upgrading to the most current technology) is considered medically necessary when the device is not functioning or when a built-in system in the pump provides notification of an impending failure.

Not Medically Necessary:

Replacement or upgrades of an implantable/intrathecal infusion pump is considered not medically necessary when requested for convenience or to upgrade to newer technology when the current components remain functional.

Implantable infusion pumps are considered not medically necessary for the infusion of heparins for thromboembolic disease or antibiotics for osteomyelitis.

All other uses of implantable infusion pumps, including fully implantable insulin pumps, are considered not medically necessary.