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Anthem Blue Cross Blue Shield / Elevance (Commercial) · intrathecal drug delivery

v1verified 2026-07-24needs re-verificationmanual-pull source

✓ conditional · commercial

Criteria checklist

0 of 5 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Severe chronic intractable pain (malignant or nonmalignant)
      • criteria:
        • trial: successful trial of opioid/nonopioid analgesic by the SAME route (intrathecal/epidural); >=50% pain reduction (binding)
      • name: Severe spasticity
      • criteria:
        • drug: intrathecal baclofen after failure of oral baclofen
      • name: Other labeled uses (cancer pain, pulmonary arterial hypertension, hepatic-artery chemotherapy)
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • satisfied by:
    • failed less-invasive therapy
    • successful intrathecal trial
  • modalities named:
    • systemic/oral analgesics
    • oral baclofen (spasticity)
Trial
  • required: yes
  • min duration days: not stated in the policy
  • success criteria:
    • logic: pain_reduction
    • pain reduction pct: 50
  • threshold is binding: yes
Psychological evaluation
  • required: no
  • must clear: no
  • note posture: not a stated gate in CG-SURG-79
Quantity limits
  • applies: yes
  • replacement: catheter codes 62350/62351/62360 MN when the pump is MN
Payor-specific notes

Anthem CG-SURG-79 covers implantable intrathecal pumps for severe chronic intractable pain (malignant/nonmalignant) after a SUCCESSFUL same-route analgesic trial (>=50% reduction, binding), plus spasticity (IT baclofen after oral failure) and other labeled uses. Like Medicare NCD 280.14, the trial is the gate (no fixed conservative-care month floor). From the fetched CG-SURG-79 (VA instance of the national guideline — confirm local instance; needs_reverification).

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Maps to Anthem CG-SURG-79. Two blocks — pick one. The same-route analgesic trial is the gate — CG-SURG-79 sets no fixed conservative-care month floor, no psych-eval gate, and no life-expectancy requirement. (The policy also enumerates other labeled uses — cancer pain, pulmonary arterial hypertension, hepatic-artery chemotherapy — with no per-use gates recorded.)

.ITDDANTHEM
.ITDDANTHEM  [PAIN]

Assessment: *** — severe chronic intractable pain (malignant / nonmalignant) of ***
etiology, refractory to less-invasive therapy including systemic and oral analgesics.

Medical necessity per Anthem CG-SURG-79 (Implantable Infusion Pumps): less-invasive therapy
with systemic and oral analgesics has failed; the policy sets no fixed duration floor, and
the qualifying gate is the trial. A preliminary trial of an opioid or nonopioid analgesic by
the same route as the planned permanent infusion (intrathecal/epidural) was performed on ***
with >=50% pain reduction, as required before permanent pump implantation.

Plan: Implantation of a programmable intrathecal drug-delivery pump and catheter
(62362 + 62350). Risks, benefits, and alternatives discussed; consent obtained.

---
.ITDDANTHEM  [SPASTICITY] — swap the assessment and trial sentences:
Assessment: *** — severe spasticity of *** etiology. Oral baclofen has failed, and the pump
is being implanted to deliver intrathecal baclofen.

Where this payor diverges from the Medicare baseline

  • trial (same-route intrathecal/epidural analgesic trial, >=50%, binding)
  • spasticity (IT baclofen after ORAL baclofen failure)
  • conservative care (no fixed month floor — the trial is the gate)
  • psych eval (not a stated gate)
  • no life-expectancy gate

Cautions

  • Anthem precertification (implantable). Catheter codes 62350/62351/62360 are MN when the pump is MN. Fetched from the VA instance of national CG-SURG-79 — confirm the local instance applies. Regenerate if `anthem-commercial-itdd.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: yes
  • pathway: Anthem precertification (implantable device)

Provenance

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Change history

  • 2026-07-24anthem pns/reactiv8/itdd: verified live via browser (JS-gated HTML) - SURG.00158 + CG-SURG-79 dates & criteria unchanged; last_verified 2026-07-24 (itdd needs_reverification kept: local-instance adoption unconfirmable) 6ab4f64dcd
  • 2026-06-29Add commercial ITDD cells: Anthem, UHC, Cigna (all covered) 3a15b25784