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DESCRIPTIONThis disposable device involves infusion of a local anesthetic into an intraoperative site for postoperative pain management. A catheter is inserted into the intraoperative site following shoulder or anterior cruciate ligament (ACL) surgery. The device enables continuous delivery and local infiltration of the intraoperative site with a local anesthetic solution, usually bupivacaine. There are several devices approved by U.S. Food and Drug Administration (FDA) for marketing. The following list includes some examples (Note: may not be inclusive):
POLICYUse of a pain control infusion pump may be considered medically necessary in the postoperative period when inserted during surgery of the knee or shoulder.
However, the charges for this disposable device should be included in the surgical facility's claim. This device does not meet the criteria for Durable Medical Equipment and may not be billed separately. It is not appropriate for providers to bill the patient for this service.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY2/1999: Approved by Medical Policy Advisory Committee (MPAC)
1/18/2001: Policy revised
5/2/2002: Type of Service and Place of Service deleted
6/23/2004: Policy reviewed, no changes
11/19/2004: Code Reference section reviewed, table added, there are no specific codes
9/21/2005: ON-Q PainBuster® added to Description section
8/7/2006: Policy reviewed, Stryker OutBound® PainPump added to Description section
12/31/2008: Policy reviewed, no changes.
02/20/2014: Policy reviewed; no changes.
08/03/2015: Code Reference section updated for ICD-10.
Hayes Medical Technology Directory
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
Not Medically Necessary Codes