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Cigna Healthcare (Commercial) · intrathecal drug delivery

v1verified 2026-07-24manual-pull source

✓ conditional · commercial

Criteria checklist

0 of 5 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Chronic non-malignant pain
      • criteria:
        • documented pathology: yes
        • conservative: failure of >=6 months provider-directed non-invasive management (active rehab exercise AND fixed-schedule opioids/analgesics)
        • behavioral attestation: no inadequately-controlled mental/behavioral condition
        • opioid taper precondition: patient agrees to >=50% reduction in systemic opioids before the trial
        • pump requires: >50% pain reduction for 8 hours during trial AND concomitant function increase
      • name: Cancer pain
      • criteria:
        • trial: failure/intolerance/contraindication to systemic opioids
        • permanent: >=50% pain reduction in trial (trial waived if advanced disease / limited survival / high-risk)
Conservative care
  • required: yes
  • min duration months: 6
  • satisfied by:
    • failed >=6 months provider-directed non-invasive management
    • contraindicated
  • modalities named:
    • active rehabilitation exercise
    • fixed-schedule opioids/analgesics
Trial
  • required: yes
  • min duration days: not stated in the policy
  • success criteria:
    • logic: pain_reduction AND function_increase
    • pain reduction pct: 50
    • note: >50% for 8 hours (non-malignant)
  • threshold is binding: yes
Psychological evaluation
  • required: yes
  • must clear: yes
  • note posture: behavioral-health attestation (no inadequately-controlled mental/behavioral condition)
Quantity limits
  • applies: yes
Payor-specific notes

Cigna delegates intrathecal pumps to eviCore CMM-210. For chronic NON-MALIGNANT pain: documented pathology, failure of >=6 months provider-directed non-invasive management (active rehab + fixed- schedule analgesics), a behavioral-health attestation, AND a distinctive precondition that the PATIENT AGREES TO >=50% SYSTEMIC OPIOID REDUCTION before the trial; the permanent pump requires >50% pain reduction for 8 hours plus a function increase. Cancer pain: trial after systemic-opioid failure (trial waived for advanced disease). From the actual fetched eviCore PDF.

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Maps to eviCore CMM-210. Two indications — pick the block. No life-expectancy eligibility gate in CMM-210; on the cancer branch, limited survival appears ONLY inside the conjunctive trial-waiver.

.ITDDCIGNA
.ITDDCIGNA  [NON-MALIGNANT PAIN]

Assessment: *** — chronic non-malignant pain of *** etiology with documented pathology on
objective findings: *** , refractory to >=6 months of provider-directed non-invasive
management.

Medical necessity per Cigna eviCore CMM-210 (Implantable Intrathecal Drug Delivery Systems):
>=6 months of provider-directed non-invasive management — including active rehabilitation
exercise and fixed-schedule opioids/analgesics — has failed. There is no inadequately
controlled mental or behavioral health condition, per attestation. The patient has agreed to
a >=50% reduction in systemic opioids before the trial. The trial on *** demonstrated >50%
pain reduction sustained for 8 hours with a concomitant increase in function, as required
before the permanent pump.

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

---
.ITDDCIGNA  [CANCER PAIN] — swap the assessment and gate sentences:
Assessment: *** — cancer-related pain with failure of, intolerance to, or contraindication
to systemic opioids. Where a trial is performed, >=50% pain reduction during the trial is
required for the permanent pump; the trial may be waived ONLY when advanced disease, limited
survival time, and high procedural risk are all present.

Where this payor diverges from the Medicare baseline

  • conservative care (>=6-month non-invasive-management floor)
  • psych (behavioral-health attestation)
  • opioid-taper precondition (>=50% systemic-opioid reduction before trial)
  • pump gate (>50% pain reduction x 8 h AND function increase)
  • cancer branch (>=50% trial gate; waiver only if advanced disease AND limited survival AND high risk)
  • no life-expectancy gate

Cautions

  • eviCore / Evernorth prior authorization. Regenerate if `cigna-commercial-itdd.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: yes
  • pathway: eviCore / Evernorth

Provenance

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Change history

  • 2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 3615c231f0
  • 2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
  • 2026-06-29Add commercial ITDD cells: Anthem, UHC, Cigna (all covered) 3a15b25784