Aetna Medicare (Medicare Advantage) · all interventional pain

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

✓ conditional · medicare advantage

Criteria checklist

0 of 1 ticked

Indications

enumerated: no
description: Aetna Medicare Advantage applies the Traditional Medicare coverage FLOOR. For procedures with an NCD/LCD (SCS, DRG, PNS, ITDD, MILD/PILD, facet, ESI, kyphoplasty, SI fusion), use the SAME criteria as the corresponding `policies/<procedure>/medicare-in-ky-*.md` cell — the plan cannot be more restrictive — plus Aetna MA's prior-authorization process. For R&N procedures where Medicare is silent (Intracept, ReActiv8, endoscopic nerve transection), the plan MAY apply its own publicly- posted internal criteria (e.g., Aetna's commercial CPB stance) — pull the plan's policy for those.

Payor-specific notes

POINTER cell. Criteria = the Traditional Medicare cell per procedure (NCD/LCD floor) + Aetna MA's PA process. The 2024 CMS rule bars MA plans from applying internal criteria more restrictive than a governing NCD/LCD; internal criteria are permitted only for R&N procedures (Intracept, ReActiv8, endoscopic). For those R&N procedures, Aetna MA likely applies Aetna's commercial CPB positions — confirm via billing. Plan PA process/vendor not independently verified (needs_reverification).

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

Prior-auth pathway

required: yes
pathway: Aetna Medicare Advantage prior authorization (confirm process/vendor)

Provenance

authority:
- type: medicare_advantage
- floor: Traditional Medicare NCD/LCD per procedure — see policies/<procedure>/medicare-in-ky-*.md
- plan um: Aetna Medicare prior authorization / utilization management (vendor/process to confirm)
- applies because: Per CMS-4201-F (2024) / 42 CFR 422.101, an MA plan must follow Traditional Medicare coverage criteria where an NCD/LCD fully establishes them, and cannot be more restrictive; plan internal criteria are allowed only where Medicare is silent (R&N procedures)
source: https://www.ecfr.gov/current/title-42/section-422.101
effective: 2024-01-01 · payor last reviewed: — · we verified: 2026-07-24 · v1

Report an issue with this cell

Change history

2026-07-24framework cells (MA x3, Medicaid IN/KY, VA): re-reviewed regulatory basis 2026-07-24 (42 CFR 422.101/CMS-4201-F, 405 IAC Art.5, KY KAR 907:3:130, 38 CFR 17.38(b) all current); plan/state-specific operational details (MA PA vendor, Medicaid interactive fee-schedule PA flags + MCO scopes, VA gated SEOC catalog/Optum manual/image-only CPG) remain gated -> needs_reverification kept; last_verified 2026-07-24 86bd4bd0b9
2026-06-29Add Medicare Advantage pointer cells (Aetna, Humana Gold HMO, HumanaChoice PPO) 86a5e15292

Embedded cell · Traditional Medicare baseline

Medicare (Traditional Part A & B) — intrathecal drug delivery

v1verified 2026-07-24

✓ conditional · medicare ncd

Criteria checklist

0 of 8 ticked

Indications

enumerated: yes
covered:
- - name: Opioid for chronic intractable pain (malignant or nonmalignant)
  - criteria:
    - life expectancy: >=3 months
    - unresponsive to: less-invasive therapy incl. systemic opioids
    - route: intrathecal or epidural
    - trial required: preliminary intraspinal opioid trial via temporary intrathecal/epidural catheter showing acceptable relief, tolerable side effects, and patient acceptance
- - name: Anti-spasmodic for severe chronic intractable spasticity
  - criteria:
    - drug: intrathecal baclofen
    - oral trial: >=6-week trial showing oral anti-spasmodics fail or cause intolerable side effects
    - trial required: favorable response to a trial intrathecal dose before implant
investigational:
- implantable pump for insulin infusion to treat diabetes (non-covered)
- implantable pump for heparin in thromboembolic disease (non-covered)

Documented pathology (objective basis)required

Conservative care

required: yes
min duration months: not stated in the policy
satisfied by:
- unresponsive to less-invasive therapy
- intolerable side effects
- contraindicated
modalities named:
- systemic/oral opioids (pain)
- oral anti-spasmodics (spasticity)
- other noninvasive methods

Trial

required: yes
min duration days: not stated in the policy
success criteria:
- logic: acceptable_pain_relief AND tolerable_side_effects AND patient_acceptance
threshold is binding: yes

Psychological evaluation

required: no
must clear: no
note posture: behavioral/psychological factors are part of patient selection; no formal clearance gate

Quantity limits

applies: no

Contraindications

known allergy/hypersensitivity to the drug (e.g., baclofen, morphine)
active infection
body size insufficient to support the device
other implanted programmable device (crosstalk risk)

Device / waveformnot_applicable

Payor-specific notes

Governed by NCD 280.14 (Infusion Pumps), Section B.2 (Implantable Infusion Pumps). Two covered pain/spasticity indications: (c) intrathecal/epidural OPIOID for severe chronic intractable pain (malignant or nonmalignant) in patients with life expectancy >=3 months who are unresponsive to less-invasive therapy — REQUIRES a preliminary intraspinal opioid trial via a temporary catheter; and (b) intrathecal BACLOFEN for severe chronic intractable spasticity unresponsive to a >=6-week oral anti-spasmodic trial, with a favorable trial intrathecal dose before implant. Implantable insulin and heparin pumps are nationally non-covered. Contraindications per NCD B.2.e (drug allergy, active infection, insufficient body size, other implanted programmable device). WPS/CGS publish no ITDD LCD — the NCD governs directly (authoritative text fetched via MCP). NCD last reviewed January 2005 (low churn).

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Maps to NCD 280.14 B.2. Two indications — pick the block. The preliminary intraspinal trial is the gate.

.ITDDMCARE

.ITDDMCARE  [PAIN]

Assessment: *** — severe chronic intractable pain (malignant / nonmalignant) of ***
etiology, unresponsive to less-invasive therapy including systemic opioids, with life
expectancy >=3 months.

Medical necessity per Medicare NCD 280.14 (Infusion Pumps, implantable): the patient has a
documented inadequate response to noninvasive methods including systemic opioids, and
behavioral factors have been addressed. A preliminary intraspinal opioid trial via a
temporary intrathecal/epidural catheter on *** gave acceptable pain relief with tolerable
side effects and patient acceptance. There is no contraindication — no drug allergy, active
infection, insufficient body size, or other implanted programmable device.

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

---
.ITDDMCARE  [SPASTICITY] — swap the assessment and trial sentences:
Assessment: *** — severe chronic intractable spasticity of *** etiology. A >=6-week trial of
oral anti-spasmodics failed or was intolerable, and the patient had a favorable response to a
trial intrathecal baclofen dose.

Where this payor diverges from the Medicare baseline

indication (pain vs spasticity)
trial line (intraspinal catheter trial)
life-expectancy gate (pain)

Cautions

Pain pump requires life expectancy >=3 months. Regenerate if `medicare-in-ky-itdd.md` `version` advances.

Prior-auth pathway

required: no
verified: no

Provenance

authority:
- type: ncd
- id: 280.14
- title: Infusion Pumps
- section: B.2 — Implantable Infusion Pumps (b. spasticity / c. chronic intractable pain)
- applies because: Implantable intrathecal drug-delivery pumps are governed by NCD 280.14; WPS (J8) and CGS (J15) publish no ITDD LCD
source: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=223
effective: 2004-12-17 · payor last reviewed: 2005-01-01 · we verified: 2026-07-24 · v1