CPT code 36260 - 36262 & 62350 , 95990, a4220 - Implantable Infusion Pump


The implantable pump is a sealed, self-powered system which is inserted under the skin by a physician. It provides a continuous controlled infusion of a drug to a select body site and can be refilled by percutaneous injection. Two separate ports are available: one for bolus injections and one for continuous infusion. Both may be utilized for blood or Cerebrospinal Fluid (CSF) withdrawals. An implantable infusion pump is utilized to administer many types of medications through the intra-arterial, intrathecal or epidural route.
Medicare will consider implantable infusion pumps and associated services medically reasonable and necessary for the conditions listed in Medicare National Coverage Determinations Manual – Pub. 100-03, Section 280.14. National Coverage Determination (NCD) specifications for indications and contraindications can be referenced in the attached Article.
  • Chemotherapy for Liver Cancer (J7799KD, E0782, E0783, E0785, E0786, 36260, 36261, 36262 and 96522)
See attached Article.
  • Antispasmodic Drugs for Severe Spasticity (J0475KD (non-compounded baclofen), J7799KD (compounded baclofen), E0782, E0783, E0785, E0786, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 95990 and 95991)
See attached Article.
  • Opioid Drugs for Treatment of Chronic Intractable Pain (J7799KD, E0782, E0783, E0785, E0786, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 95990 and 95991)
For this indication, it is useful to distinguish between pain caused by a malignancy from which the patient is not expected to recover from those non-malignant conditions that are longer term in nature. For terminal malignant conditions, the progression from a non-invasive pain control modality to a more invasive modality such as use of an implanted pump may occur more rapidly with less emphasis on behavioral approaches to pain control.
See attached Article.
  • Coverage of Other Uses of Implanted Infusion Pumps (E0782, E0783, E0785, E0786 and various drugs)
See LCD Individual Consideration procedure in the attached article.
Contraindication
The implantation of an infusion pump is contraindicated in the following patients:
  • Patients with a known allergy or hypersensitivity to the drug being used (e.g., oral baclofen and morphine).
  • Patients who have an infection.
  • Patients whose body size is insufficient to support the weight and bulk of the device.
  • Patients with other implanted programmable devices, since crosstalk between devices may inadvertently change the prescription.
LCD Individual Consideration
Coverage of other combinations of drugs used in an implanted infusion pump will be considered on an individual consideration basis. For additional details, see the LCD Individual Consideration procedure in the attached article.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11X, 12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all the Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04 Claims Processing Manual for further guidance.
026X, 027X, 0636
Revenue codes have not been identified for all procedures/services as they can be performed in a number of revenue centers within a hospital, such as emergency room (0450), operating room (0360) or clinic (0510).
Providers should report these CPT/HCPCS codes under the revenue center where they were performed.
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and CMS require the use of short CPT descriptors in policies published on the Web.
36260©
Insertion of infusion pump
36261©
Revision of infusion pump
36262©
Removal of infusion pump
62350©
Implant spinal canal cath
62351©
Implant spinal canal cath
62355©
Remove spinal canal catheter
62361©
Implant spine infusion pump
62362©
Implant spine infusion pump
62365©
Remove spine infusion device
62367©
Analyze spine infusion pump
62368©
Analyze spine infusion pump
95990©
Pump refilling, maintenance, intrathecal or intraventricular
95991©
Pump refilling, maintenance, intrathecal or intraventricular, administered by a physician
96522©
Pump refilling, maintenance, intravenous or intra-arterial
A4220
Pump refill kit
E0782
Infusion pump, implantable, non-programmable
E0783
Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)
E0785
Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement
E0786
Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)
J0475KD
Injection, baclofen (non-compounded), 10 mg
J7799KD*
NOC drugs, other than inhalation drugs, administered through DME
Note: Use J7799KD* to indicate compounded and/or combination drugs used in implantable infusion pumps including fluxuride, morphine sulfate, hydromorphone, fentanyl, compounded baclofen and ziconitide. Other drugs are not covered.
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes E0782, E0783, E0785, E0786, 36260, 36261, 36262, J7799KD (floxuridine) and 96522:
Covered for Chemotherapy used in the treatment of Liver Cancer:
153.0*–153.9*
Malignant neoplasm of colon
154.0*–154.3*
Malignant neoplasm of rectum, rectosigmoid junction and anus
154.8*
Malignant neoplasm of other sites of rectum, rectosigmoid junction and anus
Note: Use 153.0*–154.8* to represent colorectal cancer (Duke’s Class D colorectal cancer) (inclusive).
155.0
Malignant neoplasm of liver, primary
197.7
Secondary malignant neoplasm of liver, specified as secondary
230.8
Carcinoma in situ of liver and biliary system
996.2
Mechanical complication of nervous system device, implant, and graft
Medicare is establishing the following limited coverage for CPT/HCPCS codes E0782, E0783, E0785, E0786, J0475KD (non-compounded baclofen), J7799KD (compounded baclofen), 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 95990 and 95991:
Covered for Antispasmodic Drugs used in the treatment of Severe Spasticity:
323.9
Unspecified cause of encephalitis (transverse myelitis)
333.71–333.72
Symptomatic torsion dystonia
333.79
Other symptomatic torsion dystonia
334.1
Hereditary spastic paraplegia
336.9
Unspecified disease of spinal cord (degenerative myelopathy)
340
Multiple sclerosis
342.10–342.12
Spastic hemiplegia and hemiparesis
343.0–343.4
Infantile cerebral palsy
343.8–343.9
Other infantile cerebral palsy
344.00–344.04
Quadriplegia and quadriparesis
344.09
Other quadriplegia
344.1–344.2
Other paralytic syndromes
344.30–344.32
Monoplegia of lower limb
344.40–344.42
Monoplegia of upper limb
344.5
Unspecified monoplegia
344.60–344.61
Cauda equina syndrome
344.81
Locked-in state
344.89
Other specified paralytic syndromes
344.9
Paralysis, unspecified
437.8
Other ill-defined cerebrovascular disease
438.20–438.22
Hemiplegia/hemiparesis
438.30–438.32
Monoplegia of upper limb
438.40–438.42
Monoplegia of lower limb
438.50–438.53
Other paralytic syndrome
721.0–721.3
Spondylosis and allied disorders
721.41–721.42
Thoracic or lumbar spondylosis with myelopathy
722.70–722.73
Intervertebral disc disorder with myelopathy
781.0
Abnormal involuntary movements
907.2
Late effect of spinal cord injury
952.00–952.09
Cervical spinal cord injury without evidence of spinal bone injury
952.10–952.19
Dorsal (thoracic) spinal cord injury without evidence of spinal bone injury
952.2–952.4
Spinal cord injury without evidence of spinal bone injury
952.8–952.9
Spinal cord injury without evidence of spinal bone injury
996.2
Mechanical complication of nervous system device, implant, and graft
Medicare is establishing the following limited coverage for CPT/HCPCS codes E0782, E0783, E0785, E0786, J7799KD (morphine sulfate, fentanyl, hydromorphone), J7799KD (ziconitide (Prialt®)), 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 95990 and 95991:
Covered for opioid and other approved drugs used in the treatment of chronic intractable pain:
053.13
Postherpetic polyneuropathy
140.0–140.1
Malignant neoplasm of lip
140.3–140.6
Malignant neoplasm of lip
140.8–140.9
Malignant neoplasm of lip
141.0–141.6
Malignant neoplasm of tongue
141.8–141.9
Malignant neoplasm of tongue
142.0–142.2
Malignant neoplasm of major salivary glands
142.8–142.9
Malignant neoplasm of major salivary glands
143.0–143.1
Malignant neoplasm of gums
143.8–143.9
Malignant neoplasm of gums
144.0–144.1
Malignant neoplasm of floor of mouth
144.8–144.9
Malignant neoplasm of floor of mouth
145.0–145.6
Malignant neoplasm of other and unspecified parts of mouth
145.8–145.9
Malignant neoplasm of other and unspecified parts of mouth
146.0–146.9
Malignant neoplasm of oropharynx
147.0–147.3
Malignant neoplasm of nasopharynx
147.8–147.9
Malignant neoplasm of nasopharynx
148.0–148.3
Malignant neoplasm of hypopharynx
148.8–148.9
Malignant neoplasm of hypopharynx
149.0–149.1
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and pharynx
149.8–149.9
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and pharynx
150.0–150.5
Malignant neoplasm of esophagus
150.8–150.9
Malignant neoplasm of esophagus
151.0–151.6
Malignant neoplasm of stomach
151.8–151.9
Malignant neoplasm of stomach
152.0–152.3
Malignant neoplasm of small intestine, including duodenum
152.8–152.9
Malignant neoplasm of small intestine, including duodenum
153.0–153.9
Malignant neoplasm of colon
154.0–154.3
Malignant neoplasm of rectum, rectosigmoid junction and anus
154.8
Malignant neoplasm of other sites of rectum, rectosigmoid junction and anus
155.0–155.2
Malignant neoplasm of liver
156.0–156.2
Malignant neoplasm of gallbladder and extrahepatic bile ducts
156.8–156.9
Malignant neoplasm of gallbladder and extrahepatic bile ducts
157.0–157.4
Malignant neoplasm of pancreas
157.8
Malignant neoplasm of other specified sites of pancreas
158.0
Malignant neoplasm of retroperitoneum
158.8–158.9
Malignant neoplasm of peritoneum
159.0–159.1
Malignant neoplasm of other ill-defined sites within digestive organs and peritoneum
159.8–159.9
Malignant neoplasm of other ill-defined sites within digestive organs and peritoneum
160.0–160.5
Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
160.8–160.9
Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
161.0–161.3
Malignant neoplasm of larynx
161.8–161.9
Malignant neoplasm of larynx
162.0
Malignant neoplasm of trachea
162.2–162.5
Malignant neoplasm of trachea, bronchus and lung
162.8–162.9
Malignant neoplasm of trachea, bronchus and lung
163.0–163.1
Malignant neoplasm of pleura
163.8–163.9
Malignant neoplasm of pleura
164.0–164.3
Malignant neoplasm of thymus, heart and mediastinum
164.8–164.9
Malignant neoplasm of thymus, heart and mediastinum
165.0
Malignant neoplasm of upper respiratory tract, part unspecified
165.8–165.9
Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
170.0–170.9
Malignant neoplasm of bone and articular cartilage
171.0
Malignant neoplasm of connective and other soft tissue of head, face and neck
171.2–171.9
Malignant neoplasm of connective and other soft tissue
172.0–172.9
Malignant melanoma of skin
173.0–173.9
Other malignant neoplasm of skin
174.0–174.6
Malignant neoplasm of female breast
174.8–174.9
Malignant neoplasm of female breast
175.0
Malignant neoplasm of nipple and areola of male breast
175.9
Malignant neoplasm of other and unspecified sites of male breast
176.0–176.5
Kaposi’s sarcoma
176.8–176.9
Kaposi’s sarcoma
179
Malignant neoplasm of uterus, part unspecified
180.0–180.1
Malignant neoplasm of cervix
180.8–180.9
Malignant neoplasm of cervix
181
Malignant neoplasm of placenta
182.1
Malignant neoplasm of isthmus
182.8
Malignant neoplasm of other specified sites of body of uterus
183.0
Malignant neoplasm of ovary
183.2–183.5
Malignant neoplasm of ovary and other uterine adnexa
183.8–183.9
Malignant neoplasm of ovary and other uterine adnexa
184.0–184.4
Malignant neoplasm of other and unspecified female genital organs
184.8–184.9
Malignant neoplasm of other and unspecified female genital organs
185
Malignant neoplasm of prostate
186.0
Malignant neoplasm of undescended testis
186.9
Malignant neoplasm of other and unspecified testis
187.1–187.9
Malignant neoplasm of penis and other male genital organs
188.0–188.9
Malignant neoplasm of bladder
189.0–189.4
Malignant neoplasm of kidney and other and unspecified urinary organs
189.8–189.9
Malignant neoplasm of kidney and other and unspecified urinary organs
190.0–190.9
Malignant neoplasm of eye
191.0–191.9
Malignant neoplasm of brain
192.0–192.3
Malignant neoplasm of other and unspecified parts of nervous system
192.8–192.9
Malignant neoplasm of other and unspecified parts of nervous system
193
Malignant neoplasm of thyroid gland
194.0–194.6
Malignant neoplasm of other endocrine glands and related structures
194.8–194.9
Malignant neoplasm of other endocrine glands and related structures
195.0–195.5
Malignant neoplasm of other and ill-defined sites
195.8
Malignant neoplasm of other specified sites
196.0–196.3
Secondary and unspecified malignant neoplasm of lymph nodes
196.5–196.6
Secondary and unspecified malignant neoplasm of lymph nodes
196.8–196.9
Secondary and unspecified malignant neoplasm of lymph nodes
197.0–197.8
Secondary malignant neoplasm of respiratory and digestive systems
198.0–198.7
Secondary malignant neoplasm of other specified sites
198.81–198.82
Secondary malignant neoplasm of other specified sites
198.89
Secondary malignant neoplasm of other specified sites
199.0–199.2
Malignant neoplasm without specification of site
200.00–200.08
Reticulosarcoma
200.10–200.18
Lymphosarcoma
200.20–200.28
Burkitt’s tumor or lymphoma
200.30–200.38
Marginal zone lymphoma
200.40–200.48
Mantle cell lymphoma
200.50–200.58
Primary central nervous system lymphoma
200.60–200.68
Anaplastic large cell lymphoma
200.70–200.78
Large cell lymphoma
200.80–200.88
Other named variants
201.00–201.08
Hodgkin’s paragranuloma
201.10–201.18
Hodgkin’s granuloma
201.20–201.28
Hodgkin’s sarcoma
201.40–201.48
Hodgkin’s disease, Lymphocytic-histiocytic predominance
201.50–201.58
Hodgkin’s disease, nodular sclerosis
201.60–201.68
Hodgkin’s disease, Mixed cellularity
201.70–201.78
Hodgkin’s disease, lymphocytic depletion
201.90–201.98
Hodgkin’s disease, unspecified
202.00–202.08
Nodular lymphoma
202.10–202.18
Mycosis fungoides
202.20–202.28
S├ęzary’s disease
202.30–202.38
Malignant histiocytosis
202.40–202.48
Leukemic reticuloendotheliosis
202.50–202.58
Letterer-Siwe disease
202.60–202.68
Malignant mast cell tumors
202.70–202.78
Peripheral T cell lymphoma
202.80–202.88
Other malignant lymphomas
202.90–202.98
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue
203.00–203.02
Multiple myeloma
203.10–203.12
Plasma cell leukemia
203.80–203.82
Other immunoproliferative neoplasms
204.00–204.02
Acute lymphoid leukemia
204.10–204.12
Chronic lymphoid leukemia
204.20–204.22
Subacute lymphoid leukemia
204.80–204.82
Other lymphoid leukemia
204.90–204.92
Unspecified lymphoid leukemia
205.00–205.02
Acute myeloid leukemia
205.10–205.12
Chronic myeloid leukemia
205.20–205.22
Subacute myeloid leukemia without mention of remission
205.30–205.32
Myeloid sarcoma
205.80–205.82
Other myeloid leukemia
205.90–205.92
Unspecified myeloid leukemia
206.00–206.02
Acute monocytic leukemia
206.10–206.12
Chronic monocytic leukemia
206.20–206.22
Subacute monocytic leukemia
206.80–206.82
Other monocytic leukemia
206.90–206.92
Unspecified monocytic leukemia
207.00–207.02
Acute erythremia and erythroleukemia
207.10–207.12
Chronic erythremia
207.20–207.22
Megakaryocytic leukemia
207.80–207.82
Other specified leukemia
208.00–208.02
Acute leukemia of unspecified cell type
208.10–208.12
Chronic leukemia of unspecified cell type
208.20–208.22
Subacute leukemia of unspecified cell type
208.80–208.82
Other leukemia of unspecified cell type
208.90–208.92
Unspecified leukemia
210.0–210.9
Benign neoplasm of lip, oral cavity and pharynx
211.0–211.9
Benign neoplasm of other parts of digestive system
212.0–212.9
Benign neoplasm of respiratory and intrathoracic organs
213.0–213.9
Benign neoplasm of bone and articular cartilage
214.0–214.4
Lipoma
214.8–214.9
Lipoma
215.0
Other benign neoplasm of connective and other soft tissue of head, face and neck
215.2–215.9
Other benign neoplasm of connective and other soft tissue
216.0–216.9
Benign neoplasm of skin
217
Benign neoplasm of breast
218.0–218.2
Uterine leiomyoma
218.9
Leiomyoma of uterus, unspecified
219.0–219.1
Other benign neoplasm of uterus
219.8–219.9
Other benign neoplasm of uterus
220
Benign neoplasm of ovary
221.0–221.2
Benign neoplasm of other female genital organs
221.8
Benign neoplasm of other specified sites of female genital organs
222.0–222.4
Benign neoplasm of male genital organs
222.8–222.9
Benign neoplasm of male genital organs
223.0–223.3
Benign neoplasm of kidney and other urinary organs
223.81
Benign neoplasm of urethra
223.89
Benign neoplasm of other specified sites of urinary organs
224.0–224.9
Benign neoplasm of eye
225.0–225.4
Benign neoplasm of brain and other parts of nervous system
225.8–225.9
Benign neoplasm of brain and other parts of nervous system
226
Benign neoplasm of thyroid glands
227.0–227.6
Benign neoplasm of other endocrine glands and related structures
227.8–227.9
Benign neoplasm of other endocrine glands and related structures
228.00–228.04
Hemangioma and lymphangioma, any site
228.09
Hemangioma of other sites
228.1
Lymphangioma, any site
229.0
Benign neoplasm of lymph nodes
229.8–229.9
Benign neoplasm of other and unspecified sites
230.0–230.9
Carcinoma in situ of digestive organs
231.0–231.2
Carcinoma in situ of respiratory organs
231.8–231.9
Carcinoma in situ of respiratory organs
232.0–232.9
Carcinoma in situ of skin
233.0–233.2
Carcinoma in situ of breast and genitourinary system
233.30–233.32
Carcinoma in situ, female genital organ
233.39
Carcinoma in situ, other female genital organ
233.4–233.7
Carcinoma in situ of breast and genitourinary system
233.9
Other and unspecified urinary sites
234.0
Carcinoma in situ of eye
234.8–234.9
Carcinoma in situ of other and unspecified sites
235.0–235.9
Neoplasm of uncertain behavior of digestive and respiratory systems
236.0–236.7
Neoplasm of uncertain behavior of genitourinary organs
236.90–236.91
Neoplasm of uncertain behavior of other and unspecified urinary organs
236.99
Neoplasm of uncertain behavior of other and unspecified urinary organs
237.0–237.6
Neoplasm of uncertain behavior of endocrine glands and nervous system
237.70–237.73
Neoplasm of uncertain behavior of endocrine glands and nervous system, Neurofibromatosis
237.9
Neoplasm of uncertain behavior of other and unspecified parts of nervous system
238.0–238.6
Neoplasm of uncertain behavior of other and unspecified sites and tissues
238.8–238.9
Neoplasm of uncertain behavior of other and unspecified sites and tissues
239.0–239.7
Neoplasm of unspecified nature
239.89
Neoplasms of unspecified nature, other specified sites
239.9
Neoplasms of unspecified nature, site unspecified
322.9
Meningitis, unspecified
334.1
Hereditary spastic paraplegia
336.9
Unspecified disease of spinal cord
337.20–337.22
Reflex sympathetic dystrophy
337.29
Reflex sympathetic dystrophy of other specified site
338.21–338.22
Chronic pain
338.28–338.29
Chronic pain
338.3–338.4
Pain, not elsewhere classified
344.60–344.61
Cauda equina syndrome
353.6
Phantom limb (syndrome)
354.4
Causalgia of upper limb
355.71
Causalgia of lower limb
356.9
Unspecified idiopathic peripheral neuropathy
719.40–719.49
Pain in joint
720.0–720.2
Ankylosing spondylitis and other inflammatory spondylopathies
720.81
Inflammatory spondylopathies in diseases classified elsewhere
720.89
Other inflammatory spondylopathies
720.9
Unspecified inflammatory spondylopathy
721.0–721.3
Spondylosis and allied disorders
721.41–721.42
Thoracic or lumbar spondylosis with myelopathy
721.5–721.8
Spondylosis and allied disorders
721.90–721.91
Spondylosis of unspecified site
722.0
Displacement of cervical intervertebral disc without myelopathy
722.10–722.11
Displacement of thoracic or lumbar intervertebral disc without myelopathy
722.2
Displacement of intervertebral disc, site unspecified, without myelopathy
722.30–722.32
Schmorl’s nodes
722.39
Schmorl’s nodes of other spinal region
722.4
Degeneration of cervical intervertebral disc
722.51–722.52
Degeneration of thoracic or lumbar intervertebral disc
722.6
Degeneration of intervertebral disc, site unspecified
722.70–722.73
Intervertebral disc disorder with myelopathy
722.80–722.83
Postlaminectomy syndrome
722.90–722.93
Other and unspecified disc disorder
723.0–723.9
Other disorders of cervical region
724.00–724.03
Spinal stenosis, other than cervical
724.09
Spinal stenosis of other region
724.1–724.6
Other and unspecified disorders of back
724.70–724.71
Disorders of coccyx
724.79
Other disorders of coccyx
724.8–724.9
Other and unspecified disorders of back
733.13
Pathological fracture of vertebrae
733.45
Aseptic necrosis of bone, jaw
733.90
Disorder of bone and cartilage, unspecified
790.21–790.22
Abnormal glucose
790.29
Other abnormal glucose
790.6
Other abnormal blood chemistry (hyperglycemia)
791.0
Proteinuria
791.5
Glycosuria
796.1
Abnormal reflex
953.0–953.3
Injury to nerve roots and spinal plexus
996.2
Mechanical complication of nervous system device, implant, and graft
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
  • As indicated in the applicable section of the LCD, medical record documentation maintained in the patient’s file should support indications. This information is normally found in the office records, history and physical and/or Certificate of Medical Necessity (CMN).
  • If the indication for the implantable infusion pump is for reasons other than chemotherapy for liver cancer (primary hepatocellular carcinoma or Duke’s Class D colorectal cancer in whom the metastases are limited to the liver), antispasmodic drugs for severe spasticity or opioid drugs for treatment of chronic intractable pain, or the diagnosis is not indicated in the applicable covered indication, documentation supporting medical necessity for the pump and/or medication must be submitted with the redetermination request.
  • Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
  • Ziconotide (Prialt®) intrathecal infusion documentation must meet FDA-approved indication that the patient is intolerant of or refractory to other treatment, such as systemic analgesics, adjunctive therapies or intrathecal therapy morphine in the treatment of severe chronic pain.
Appendices
N/A
Utilization Guidelines
N/A
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Integration
TrailBlazer adopted the TrailBlazer LCD, “Implantable Infusion Pump,” for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of sources of information is found with original contractor LCDs.
Other Contractor Local Coverage Determinations
Implantable Infusion Pump,” Noridian Administrative Services, LLC LCD, (CO) L14874.
Implantable Infusion Pump,” TrailBlazer LCD, (00400) L13340, (00900) L13342.
Implantable Infusion Pump,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (NM, OK) L14744.

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