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
|
Sézary’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