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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.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY2/1999: Approved by Medical Policy Advisory Committee (MPAC)
01/18/2001: 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.
06/01/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
Hayes Medical Technology Directory
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
Not Medically Necessary Codes