Subject:
Implantable Intrathecal Drug Delivery Systems
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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CMM-210: Implantable Intrathecal Drug Delivery Systems
| CMM-210.1: Definitions |
| CMM-210.2: General Guidelines |
| CMM-210.3: Indications |
| CMM-210.4: Non-Indications |
| CMM-210.5: Replacement |
| CMM-210.6: Procedure (CPT®) Codes |
| CMM-210.7: References |
CMM-210.1 Definitions
† An implantable intrathecal drug delivery system (Pain pump or Baclofen pump) is a device used for the continuous infusion of a drug directly into the cerebrospinal fluid via a catheter placed in the intrathecal or epidural space. A pump is placed in the subcutaneous tissue of the abdomen and connected to the catheter. The pump reservoir holds the medication(s), and the pump is programmed to give a set dose of medication over time. For most individuals, it should be used as part of a program to facilitate restoration of function and return to activity, and not just for pain reduction. An intrathecal drug delivery trial can be accomplished by either a single intrathecal bolus injection or an intrathecal catheter infusion.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
CMM-210.2: General Guidelines
† Please note: this guideline does not apply to epidural injections administered for obstetrical or surgical epidural anesthesia.
† The determination of medical necessity for the performance of an implantable intrathecal or epidural drug delivery system is always made on a case-by-case basis.
CMM-210.3 Indications
† The use of an implantable intrathecal or epidural drug delivery system is considered medically necessary for ANY of the following indications when the associated criteria are met:
® Nonmalignant, chronic intractable pain (e.g., failed back surgery syndrome with low back pain and/or radicular pain, post-herpetic neuralgia, complex regional pain syndrome
® Severe, refractory spasticity or chronic intractable dystonia in individuals who are unresponsive to or cannot tolerate oral anti-spasticity agents (i.e., Baclofen [Lioresal®]) (i.e., intrathecal injection of Baclofen)
® Cancer-related pain
Nonmalignant, Chronic Intractable Pain
† A trial with a percutaneous intrathecal or epidural drug delivery system for nonmalignant chronic intractable pain is considered medically necessary when ALL of the following criteria have been met:
® There is a documented pathology (i.e., an objective basis for the pain complaint)
® Failure of a sufficient trial of at least six (6) months of provider-directed noninvasive pain management, including active rehabilitative exercise and fixed schedule dosing of opioids or other analgesics unless contraindicated and the reason(s) for the contraindication(s) is/are documented in the medical record
® Further surgical intervention or other treatment is not indicated or likely to be effective
® Statement from a primary care provider, neurologist, physiatrist, psychiatrist, psychologist, or other licensed behavioral and/or medical health care provider attesting to the absence of untreated, underlying mental health conditions/issues (e.g., depression, drug, alcohol abuse) as a major contributor to chronic pain.
® Individual agrees to a 50% reduction in systemic opiates prior to undergoing an intrathecal opiate trial.
† A permanent implantable intrathecal or epidural drug delivery system for the above listed pain conditions is considered medically necessary if the individual has met the above criteria for a preliminary trial and has experienced > 50% reduction in pain for 8 hours and concomitant increase in function during an appropriate trial.
Severe, Refractory Spasticity/Chronic Intractable Dystonia
† A trial with a percutaneous intrathecal drug delivery system for severe, refractory spasticity or chronic intractable dystonia is considered medically necessary for EITHER of the following indications:
® There is failure, contraindication or intolerance to at least a six-week trial of oral antispasmodic drugs and physical therapy.
® Individual has a baseline average Ashworth score of at least 3 (or a Modified Ashworth score of 2) and a Spasm Frequency score of at least 2.
¡ An Ashworth score of 3 represents a considerable increase in muscle tone when testing resistance to passive movement about a joint with varying degrees of velocity.
¡ A Modified Ashworth score of 2 represents a slight increase in muscle tone followed by minimal resistance of the range of motion.
¡ A Spasm Frequency score of 2 represents a member’s self-report of between 1 to 5 spasms per day.
† A permanent implantable infusion for the treatment of chronic intractable spasticity or chronic intractable dystonia is considered medically necessary when a preliminary trial of intrathecal antispasmodic drug administration, that meets the above medical necessity criteria, demonstrates a beneficial clinical response (e.g., demonstrates at least a 2-point reduction in the Ashworth or Spasm Frequency score for 4 hours following an intrathecal trial bolus of Baclofen)
Cancer-Related Pain
† A trial with a percutaneous intrathecal or epidural drug delivery system for cancer-related pain is considered medically necessary when there is failure, intolerance, or contraindication to noninvasive methods of pain control, including systemic opioids.
† A permanent implantable intrathecal or epidural drug delivery system for the above listed pain conditions is considered medically necessary if the individual has met the above criteria for a preliminary trial and has experienced at least a 50% reduction in pain during an appropriate trial.
† Please Note: A trial with a percutaneous intrathecal or epidural drug delivery system for cancer-related pain is not required in the presence of advanced disease, when survival time is limited, and when the individual is considered at high risk for procedures.
CMM-210.4: Non-Indications
† An intrathecal or epidural drug delivery system is considered investigational for ANY other indication, including the following:
® Cancer-related pain, spastic/dystonic, or other pain conditions that do not meet the above criteria
® Administration of chemotherapy
® Administration of antibiotics
CMM-210.5: Replacement
† Replacement of an implanted intrathecal or epidural drug infusion system is considered medically necessary when BOTH of the following criteria have been met:
® The existing device is documented to be nearing end of battery life, will no longer be beneficial and cannot be repaired, or a built-in component provides notification of impending failure
® There is no evidence to suggest the device has been abused or neglected
† Replacement of an implantable intrathecal infusion pump is considered not medically necessary when the existing infusion pump and/or components remain functional.
CMM-210.6 Procedure (CPT®) Codes
| This guideline relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required. |
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| Code Description/Definition |
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) |
62324 | 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, cervical or thoracic; without imaging guidance. |
62325 | 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, cervical or thoracic; 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. |
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 |
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 |
62365 | Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion |
62367 | Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming |
62368 | Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming |
95990 | Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed |
95991 | Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump when performed; requiring skill of a provider or other qualified health care professional |
| This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the health plan and is based on the individual’s policy or benefit entitlement structure as well as claims processing rules. |
Medicare Coverage:
Medicare Advantage Products differs from the Horizon BCBSNJ Medical Policy. There are several NCD and LCDs applicable to implantable intrathecal or epidural drug delivery system.
Per LCD L35112, An implantable infusion pump is covered when used to administer anti-spasmodic drugs intrathecally (e.g., baclofen) to treat chronic intractable spasticity in patients who have proven unresponsive to less invasive medical therapy as determined by the following criteria:
· As indicated by at least a 6-week trial, the patient cannot be maintained on non-invasive methods of spasm control, such as oral anti-spasmodic drugs, either because these methods fail to control adequately the spasticity or produce intolerable side effects. And
· Prior to pump implantation, the patient must have responded favorably to a trial intrathecal dose of the anti-spasmodic drug.
An implanted infusion pump for chronic pain is covered by Medicare when used to administer opioid drugs, singly or in combination with other opioid or non-opioid drugs, intrathecally, for treatment of severe chronic intractable pain of malignant or nonmalignant origin in patients who have a life expectancy of at least three (3) months and who have proven unresponsive to less invasive medical therapy. In order to be considered medically reasonable and necessary, all of the following criteria must be met:
· The administration of the medication must require administration through the intrathecal route and be effective on a long-term basis.
· The history of the patient's prior treatment should show oral or subcutaneous medication treatment was ineffective or complicated by unacceptable side effects.
· The patient's medical condition must require the use of an infusion pump for pain relief.
· The type and dosage of the medication must reasonably be expected to alleviate or reduce the pain.
In addition, an evaluation by an orthopedic surgeon, neurologist, neurosurgeon, oncologist, pain management physician or other specialist familiar with the underlying disease is required to validate that other treatments have failed to alleviate the pain, unless such a provider is currently managing the patient and documents that such a situation exists in the record. Documentation to support that the patient is unresponsive to less invasive medical therapy must be in the patient's medical record and made available upon request.
If the above criteria have been met, a preliminary trial of intraspinal opioid or non-opioid drug administration with a temporary intrathecal catheter to substantiate acceptable pain relief, degree of side effects including effects on the activities of daily living, and patient acceptance is considered reasonable and necessary. This trial could also be verified with a single-shot intrathecal injection rather than a continuous infusion.
For Drugs currently approved for pain management through an implantable infusion pump include: (Refer to Local Coverage Article A54100 Compounded Drugs Used in an Implantable Infusion Pump for additional information on billing and coding for non-compounded and compounded drugs.)
· Bupivicaine
· Clonidine
· Droperidol
· Fentanyl
· Hydromorphone (Dilaudid®)
· Ketamine
· Morphine
· Prialt
· Sufentanil
· Tetracaine
Individual Consideration
Coverage of other combinations of drugs used in an implanted infusion pump may be considered on an individual consideration basis, on appeal, if LCD 35112 criteria are met and if the drugs or combinations thereof can be supported by levels of evidence as outlined in Local Coverage Article A53049 Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents for the diagnoses requested.
Drugs for use in implantable pumps, unlike other drugs referred to in Local Coverage Article A53049 Approved Drugs and Biologicals must be pre-approved by the Contractor if they do not appear on the current approved list for infusion through an implantable infusion pump. (Reference Local Coverage Article A54100 Compounded Drugs Used in an Implantable Infusion Pump for the list of covered compounded drugs).
The Medical Record for claims submitted for drugs such as Duraclon, methadone, sufentanil or bupivicaine added to the compounded drug regimen for chronic intractable pain must demonstrate that there has been an improvement in the pain level with the addition of these drugs versus a pre-existing regimen without them, such that the addition of these drugs would be considered medically necessary for the treatment of chronic pain in a particular patient.
A preliminary trial of the intraspinal (intrathecal) opioid drug or non-opioid administration must be undertaken with a temporary intrathecal catheter or by direct intrathecal injection to substantiate adequate acceptable pain relief and the degree of side effects (including the effects on the activities of daily living) and the patient’s acceptance of the therapy must be documented in the patient's record.
Local Coverage Determination (LCD): Implantable Infusion Pump (L35112). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370.
Also see Local Coverage Article: Compounded Drugs Used in an Implantable Infusion Pump (A54100) for proper billing of Compounded Drugs Used in an Implantable Infusion Pump. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54100&ver=33&Date=01%2f28%2f2016&DocID=A54100&bc=hAAAAAgAAAAAAA%3d%3d&.
National Coverage Determination (NCD) for Infusion Pumps (280.14). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx
Local Coverage Determination (LCD): Epidural Injections for Pain Management (L36920). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370.
Local Coverage Article: Billing and Coding: Implantable Infusion Pump (A56778). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Implantable Intrathecal Drug Delivery Systems
Infusion Pumps for Severe Intractable Pain
Implantable Infusion Pumps
SynchroMed Infusion System
Codman 3000 Pump
References:
1. Ackerman L, Follett K, Rosenquist R. Long-term outcomes during treatment of chronic pain with intrathecal clonidine or clonidine/opioid combinations. J Pain Symptom Manage. 2003;;26(1):668-677.
2. American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guideline, 2nd Ed. 2008.
3. American Medical Association. Current Procedural Terminology – 2014 Professional Edition.
4. Anderson V, Burchiel K. A prospective study of long term intrathecal morphine in the management of chronic nonmalignant pain. Neurosurgery. 1999;44:289-300.
5. Anderson V, Cooke B, Burchiel K. Intrathecal hydromorphone for chronic nonmalignant pain: a retrospective study. Pain Med. 2001;2(4):287-297.
6. Angel I, Gould H Jr, Carey M. Intrathecal morphine pump as a treatment option in chronic pain of nonmalignant origin. Surg Neurol. 1998;49(1):92-98.
7. Boswell M, Shah R, Everett C, et al. Interventional Techniques: Evidence-based Practice Guidelines in The Management of Chronic Spinal Pain: Evidence-Based Practice Guidelines. Pain Physician. 2005;8:1-47.
8. Brown J, Klapow J, Doleys D, et al. Disease-specific and generic health outcomes: a model for the evaluation of long-term intrathecal opioid therapy in noncancer low back pain patients. Clin J Pain. 1999;15:122-131.
9. Dahm P, Nitescu P, Appelgren L, Curelaru I. Efficacy and technical complications of long-term continuous intraspinal infusions of opioid and/or bupivacaine in refractory nonmalignant pain: a comparison between the epidural and the intrathecal approach with externalized or implanted catheters and infusion pumps. Clin J Pain. 1998;14:4-16.
10. Dario A, Scamoni C, Picano M, et al. The infection risk of intrathecal drug infusion pumps after multiple refill procedures. Neuromodulation. 2005;8(1):36-39.
11. Deer T, Krames ES, Hassenbusch SJ, Burton A, Caraway D, Dupen S, et al. Polyanalgesic consensus conference 2007: Recommendations for the management of pain by intrathecal (intraspinal) drug delivery: Report of an interdisciplinary expert panel. Neuromodulation. 2007;10(4):300-328.
12. Deer TR, Hayek SM, Pope JE, et al. The polyanalgesic consensus conference (PACC): recommendations for training of intrathecal drug delivery infusion therapy. Neuromodulation. 2017;20:133-154. DOI: 10.1111/ner.12543.
13. Deer TR, Kim C, Bowman R, Tolentino D, Stewart C, Tolentino W. Intrathecal ziconotide and opioid combination therapy for noncancer pain: an observational study. Pain Physician. 2009;12(4):E291-E296.
14. Deer TR, Smith HS, Burton AW, et al. Comprehensive Consensus Based Guidelines on Intrathecal Drug Delivery Systems in the Treatment of Pain Caused by Cancer Pain. Pain Physician. 2011; 14:E283-E312.
15. Deer TR, Prager J, Levy R, Rathmell J, Buchser E, Burton A, et al. Polyanalgesic Consensus Conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation. 2012a;15(5):436-464.
16. Deer TR, Prager J, Levy R, Burton A, Buchser E, Caraway D, et al. Polyanalgesic Consensus Conference--2012: recommendations on trialing for intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation. 2012b;15(5):420-35.
17. Deer T, Chapple I, Classen A, et al. Intrathecal drug delivery for treatment of chronic low back pain: report from the National Outcomes Registry for Low Back Pain. Pain Med. 2004;5(1):6-13.
18. Deer T Current and future trends in spinal cord stimulation for chronic pain. Curr Pain Headache Rep. 2001;5(6):503-509.
19. Du Pen S, Du Pen A, Hillyer J. Intrathecal hydromorphone for intractable nonmalignant pain: a retrospective study. Pain Med. 2006;7(1):10-15.
20. Guillaume D, Van Havenbergh A, Vloeberghs M, et al. A clinical study of intrathecal baclofen using a programmable pump for intractable spasticity. Arch Phys Med Rehabil. 2005;86:2165-2171.
21. Hamza M, Doleys DM, Saleh IA, Medvedovsky A, Verdolin MH, Hamza M. A Prospective, Randomized, Single-Blinded, Head-to-Head Long-Term Outcome Study, Comparing Intrathecal (IT) Boluses With Continuous Infusion Trialing Techniques Prior to Implantation of Drug Delivery Systems (DDS) for the Treatment of Severe Intractable Chronic Nonmalignant Pain. Neuromodulation. 2015 Oct;18(7):636-48.
22. Hassenbusch S, Portenoy R, Cousins M, et al. Polyanalgesic Consensus Conference 2003: an update on the management of pain by intraspinal drug delivery--report of an expert panel. J Pain Symptom Manage. 2004;27(6):540-563.
23. Krames E. Intraspinal opioid therapy for chronic nonmalignant pain: current practice and clinical guidelines. J Pain Symptom Manage. 1996;11(6):333-352.
24. Kumar K, Hunter G, Demeria D. Treatment of chronic pain by using intrathecal drug therapy compared with conventional pain therapies: a cost-effectiveness analysis. J Neurosurg. 2002;97(4):803-810.
25. Miele V, Price K, Bloomfield S, et al. A review of intrathecal morphine therapy related granulomas. Eur J Pain. 2006;10(3):251-261.
26. Modified Ashworth scale and spasm frequency score in spinal cord injury: reliability and correlation. Spinal Cord (2016) 54, 702–708 (2016).
27. North American Spine Society. NASS Coverage Policy Recommendations: Intrathecal Drug Delivery Systems. Burr Ridge, IL: North American Spine Society. March 2017.
28. Nguyen H, Garber J, Hassenbusch S. Spinal analgesics. Anesth Clin of NA. 2003;21(4).
29. Osenbach R, Harvey S. Neuraxial infusion in patients with chronic intractable cancer and noncancer pain. Curr Pain Headache Rep. 2001;5(3):241-9.
30. Penn RD et al. Intrathecal baclofen for severe spinal spasticity. N Engl J Med 1989; 320: 1517–1521.
31. Raffaeli W, Marconi G, Fanelli G, et al. Opioid-related side-effects after intrathecal morphine: a prospective, randomized, double-blind dose-response study. Eur J Anaesthesioloy. 2006;23:605-10.
32. Rauck R, Wallace M, Leong M, et al; Ziconotide 301 Study Group. A randomized, double-blind, placebo-controlled study of intrathecal ziconotide in adults with severe chronic pain. J Pain Symptom Manage. 2006;31(5):393-406.
33. Staal C, Arends A, Ho S.A self-report of quality of life of patients receiving intrathecal baclofen therapy. Rehabil Nurs. 2003 Sep-Oct;28(5):159-63.
34. Thimineur M, Kravitz E, Vodapally M. Intrathecal opioid treatment for chronic non-malignant pain: a 3-year prospective study. Pain. 2004;109(3):242-249.
35. Turner J, Sears J, Loeser J. Programmable intrathecal opioid delivery systems for chronic noncancer pain: a systematic review of effectiveness and complications. Clin J Pain. 2007;23(2):180-95.
36. van Hilten B, van de Beek W, Hoff J, et al. Intrathecal baclofen for the treatment of dystonia in patients with reflex sympathetic dystrophy. N Engl J Med. 2000;343(9):625-630.
37. Waara-Wolleat K, Hildebrand K, Stewart G. A review of intrathecal fentanyl and sufentanil for the treatment of chronic pain. Pain Med. 2006;7:251-259.
38. Winkelmuller M, Winkelmuller W. Long-term effects of continuous intrathecal opioid treatment in chronic pain of nonmalignant etiology. J Neurosurg. 1996;85:458-467.
39. Workloss Data Institute. Official Disability Guidelines.
40. Yoshida G, Nelson R, Capen D, Nagelberg et al. Evaluation of continuous intraspinal narcotic analgesia for chronic pain from benign causes. Am J Orthop. 1996;25(10):693-694.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
62320
62321
62322
62323
62324
62325
62326
62350
62351
62355
62360
62361
62362
62365
62367
62368
95990
95991
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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