Implantation of an infusion pump is reported as 36260.

Payment may be made for surgical implantation of an infusion pump for the following FDA-approved usages and when the administered medications are FDA-approved for the route of administration and the medical condition:

1. Delivery into the superior vena cava;
2. Delivery into the epidural area for the treatment of severe or unremitting pain in cancer patients who are unresponsive to conventional forms of analgesia;
3. Intra-arterial administration of antineoplastic agents;
4. Intrathecal injection of baclofen for severe spasticity of spinal cord origin in patients who are unresponsive to or who cannot tolerate oral baclofen therapy;
5. Intrathecal administration, including Ziconotide (Prialt®), for the treatment of chronic intractable pain of nonmalignant or malignant origin.

NOTE:

See Medical 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 (96416, 96425) in addition to code 96522 is determined according to individual or group customer benefits. Payment can be made for the pump filling and maintenance (95990, 95991, 96522) when provided in conjunction with covered FDA approved pump usages.

NOTE:

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

Place of Service: Outpatient

The implantation of an infusion pump is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the need to titrate medication to achieve control of symptomatology and the need for on-going monitoring for potential complications related to the specific medication being administered.

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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Taira N, Shinozaki Y, Kawai T, Miyake T, Hara F, Nakajima T. Palliation for a recurrent lung cancer patient with superior vena cava syndrome by arterial infusion of CDDP through the implantable port system--a case report. Gan To Kagaku Ryoho. 1999 Mar;26(4):531-3.

Guglielmino A, Sorbello M, Fazzio S, et al. Continuous intrathecal baclofen administration by a fully implantable electronic pump for severe spasticity treatment: our experience. Minerva Anestesiol. 2006 Oct;72(10):807-20.

Roche N, Even-Schneider A, Bussel B, Bensmail D. Management of increase in spasticity in patients with intrathecal baclofen pumps. Ann Readapt Med Phys. 2007 Mar;50(2):93-9.

Wu CF, Chen CM, Chen CH, Shieh TY, Sheen MC. Continuous intraarterial infusion chemotherapy for early lip cancer. Oral Oncol. 2007 Sep;43(8):825-30.

Mercadante S, Intravaia G, Villari P, et al. Intrathecal treatment in cancer patients unresponsive to multiple trials of systemic opioids. Clin J Pain. 2007 Nov-Dec;23(9):793-8.

Ethans K. Intrathecal baclofen therapy: indications, pharmacology, surgical implant, and efficacy. Acta Neurochir Suppl. 2007;97(Pt 1):155-62.

Koulousakis A, Kuchta J, Bayarassou A, Sturm V. Intrathecal opioids for intractable pain syndrome. Neurochir Suppl. 2007;97(Pt 1):43-8.

Taira T. Chronic intrathecal drug administration for the control of intractable pain. Brain Nerve. 2008 May;60(5):509-17.

Ilias W, le Polain B, Buchser E, Demartini L; oPTiMa study group. Patient-controlled analgesia in chronic pain patients: experience with a new device designed to be used with implanted programmable pumps. Pain Pract. 2008 May-Jun;8(3):164-70.

InterQual® Level of Care Criteria 2010. Acute Care Adult. McKesson Health Solutions, LLC. 2010. ADLT-147.