The charge for the implantation of the pump includes payment for the surgical placement and any other related procedures, such as a cholecystectomy, which are performed to avoid migration of the chemotherapy agent to other organs.

Payment may be made for both methods of surgical implantation for the following FDA-approved usages:

1. Delivery of morphine into the superior vena cava.
2. Delivery of heparin (usually delivered into the superior vena cava) for the treatment of severe thromboembolic disease.
3. Regional delivery of antibiotics for the treatment of chronic
   osteomyelitis.
4. Delivery of morphine into the epidural area for the treatment of severe or unremitting pain in cancer patients who are unresponsive to conventional forms of analgesia.
5. Intra-arterial administration of antineoplastic agents.
6. Intrathecal injection of baclofen for severe spasticity of spinal cord origin in patients who are unresponsive to or who cannot tolerate oral baclofen therapy.
7. Intrathecal administration of morphine or Ziconotide (Prialt®) for the treatment of chronic intractable pain of nonmalignant or malignant origin.

NOTE:

See Mountain State Policy Bulletin I-76 for guidelines on Ziconotide (Prialt®).

Generally, the pump has been approved for implantation in the thoracic or abdominal area for infusion into the nervous and vascular systems. However, drug delivery directly into the neural tissue or ventricle spaces of the brain via the implantable infusion pump is experimental/investigational. Any method of delivery/conditions not listed above, are not FDA-approved and should be denied as experimental/investigational. All services performed in connection with an experimental/investigational usage should also be denied. When eligible, separate charges for the implantable pump itself are payable.

Infusion of saline solution and bacteriostatic water used as diluting agents or to keep the catheter patent are considered pump maintenance. Coverage for chemotherapy administration (96414, 96425) in addition to code 96530 is determined according to individual or group customer benefits. Payment can be made for the pump filling and maintenance (95990, 95991, 96530) when provided in conjunction with covered FDA approved pump usages.

NOTE:

See Medical Policy Bulletin E-17 for information on the portable infusion pump.

Description

The implantable infusion pump is a drug delivery system that provides continuous infusion of an agent (e.g., morphine, heparin) at a constant and precise flow rate. It is frequently used to deliver chemotherapy directly to the hepatic artery or superior vena cava.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

The use of the implantable pump for the treatment of diabetes and for the infusion of FDA-approved chemotherapy drugs is covered.

PRN References

02/1996, Insertion of reservoir-procedure code 61215 clarified