Humana Implantable Infusion Pumps for Pain or Spasticity - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals. Type Title ID Number NCD Infusion Pumps 280.14 Jurisdiction Medicare Administrative Contractors (MACs) Applicable States/Territories Implantable Infusion Pumps for Pain or Spasticity Page: 2 of 7 LCA LCA LCD LCA Billing and Coding: Implantable Infusion Pumps for Chronic Pain Billing and Coding: Implantable Infusion Pumps for Chronic Pain Implantable Infusion Pump A55239 A55323 L33461 A56695 JE - Noridian Healthcare Solutions, LLC JF - Noridian Healthcare Solutions, LLC JJ - Palmetto GBA (Part A/B MAC) CA, HI, NV, American Samoa, Guam, Northern Mariana Islands AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AL, GA, TN JM - Palmetto GBA Part A/B MAC) NC, SC, VA, WV Description Implantable infusion pumps (IIPs) for pain or spasticity (also referred to as implantable drug delivery systems [IDDS] or targeted drug delivery [TDD] systems) are devices that deliver medications via intrathecal catheters directly into the cerebrospinal fluid in the spine. IIPs can be programmed for continuous or variable rates of infusion. Examples of IIPs include, but may not be limited to: • Prometra Programmable Infusion Pump System • Prometra II Programmable Pump • SynchroMed II (may include the myPTM remote control programmer) Postoperative disposable ambulatory regional anesthesia pumps may be single use elastomeric or spring- loaded devices which deliver a continuous, preset dose of pain medication; some newer models also allow for bolus injections with adjustable lockout times. These devices are placed at the end of the procedure in or near the surgical area in an attempt to control postoperative pain and are sent home with the individual at discharge. The individual or caregiver is instructed on removal of the device. Examples of these devices include, but may not be limited to: • ACTion Block Pain Pump • Action Fuser Pain Pump • AutoFuser Disposable Pain Pump • On-Q Fixed Flow Rate Pump • On-Q Pump with ONDEMAND Bolus Button • On-Q Pump with Select-A-Flow Variable Rate Controller • On-Q with Select-A-Flow Variable Rate Controller and ONDEMAND Bolus Button Another type of pump used for the immediate postoperative period for an individual after they are discharged from the hospital or surgery center is the single-use (ie, used for one individual, and then disposed of via a recycling center) Nimbus PainPRO Postoperative Pain Pump. It differs from the elastomeric or spring-loaded devices in that it is battery powered and uses a programmed intermittent bolus (PIB) which purportedly puts pressure and volume behind the catheter infusion, enhancing medication spread. Implantable Infusion Pumps for Pain or Spasticity Page: 3 of 7 Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria: Implantable Infusion Pumps for Pain or Spasticity The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider MCG Guidelines. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage