For Dates of Service Before January 1, 2017

Intrathecal Infusion Pumps for Spasticity or Pain

Placement of IIP for the treatment of spasticity or pain is covered by ForwardHealth with PA.

Implantation of spinal cord pumps for infusion may provide benefit when treating chronic, intractable spasm and/or pain caused by diseases of, or injury to, the brain and/or spinal cord. The implantation procedure is invasive and has a significant complication rate; therefore, it should only be considered for conditions where evidence supports its effectiveness and where more conservative methods to control spasm and/or pain have failed.

Baclofen (Lioresal) is a derivative of GABA that acts specifically at the spinal end of the upper motor neurons to cause muscle relaxation. Intrathecal baclofen may be indicated for patients with chronic, intractable spasticity.

Intrathecal medication for pain management is an alternative for cancer patients and other severe, chronic, and intractable pain sufferers whose pain is not relieved by conventional drugs or other methods of opiate delivery. It may also serve as an alternative for patients who cannot tolerate the side effects of systemic administration of opioids in the doses needed for adequate pain management. ForwardHealth covers an IIP when used to administer opioid drugs, ziconotide, and/or clonidine intrathecally or epidurally for those patients who have proven unresponsive to less invasive medical therapy.

ForwardHealth considers the implantation of an IIP for delivery of baclofen or opioid pain medication a treatment of last resort.

Intrathecal Infusion Pumps for Treatment of Spasticity Screening Dose

Intrathecal pumps for baclofen for the treatment of spasticity require that a screening dose be administered prior to implantation surgery. Providers are required to use one of the following CPT procedure codes, along with modifier U5, to designate the baclofen screening dose:

• 62310 with modifier U5 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, eipidural or subarachnoid; cervical or thoracic).
• 62311 with modifier U5 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, eipidural or subarachnoid; lumbar or sacral [caudal]).

Intrathecal Infusion Pumps for Treatment of Pain Trial Period

Intrathecal pumps for opioid delivery for the treatment of pain require that a trial period be completed prior to the implantation surgery. Providers are required to use one of the following CPT procedure codes, along with modifier U5, to designate the opioid pain medication trial period:

• 62310 with modifier U5 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, eipidural or subarachnoid; cervical or thoracic).
• 62311 with modifier U5 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, eipidural or subarachnoid; lumbar or sacral [caudal]).

Claims submitted with the U5 modifier will be referenced by ForwardHealth clinicians when the provider seeks authorization for permanent pump implantation. Claims that do not include the U5 modifier will not be considered eligible trials for reference in requesting the permanent pump implantation.

Note: Trial periods for opioid delivery for the treatment of pain must last a minimum of 24 hours. A separate PA request is required for both the trial period and the implantation surgery of an IIP for the treatment of pain.

Permanent Implantation for Treatment of Spasticity or Pain

Providers are required to use one of the following CPT procedure codes to designate permanent implantation of an IIP for treatment of spasticity or pain:

• 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).

Screening doses, trial periods, and implantation surgeries that do not meet the PA approval criteria are noncovered. ForwardHealth will not reimburse providers for any charges related to noncovered pump implantation surgeries. Associated charges for the IIP device and facility charges will only be reimbursed if surgery services for the implantation of the pump have been approved and rendered.