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L.7.01.405
Morphine may be administered by the intravenous, intramuscular, subcutaneous, epidural or intrathecal routes of administration. It is used for the management of severe pain which may occur post-surgically, after severe trauma, or during the progression of a pathological disease process (e.g., cancer).
Access of the route of drug administration may be gained by direct conventional transepidermal injection techniques in the appropriate area, injection through an external catheter port, or by injection through a previously implanted port/reservoir catheter site. Morphine may be administered by intermittent injection (discreet intervals) or by continuous infusion when diluted in compatible solutions.
Epidural or intrathecal morphine administration for the management of severe, intractable pain is considered eligible for coverage.
Intraventricular administration of morphine is considered investigational.
None
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of 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. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
9/1994: Approved by Medical Policy Advisory Committee (MPAC)
2/14/2002: Investigational definition added, Managed Care Requirements deleted, Prior Authorization put under the Policy Section
3/5/2002: Prior authorization deleted
4/26/2002: Type of Service and Place of Service deleted
11/12/2003: Code Reference section updated, CPT code range 62274-62279 deleted
08/28/2015: Code Reference section updated for ICD-10. Removed ICD-9 procedure code 99.29 from the Code Reference section.
06/01/2016: Policy number L.7.01.405 added. Investigative definition updated in Policy Guidelines section.
12/30/2016: Code Reference section updated to add new 2017 CPT codes 62320, 62321, 62322, 62323, 62324, 62325, 62326, and 62327. Removed deleted HCPCS codes J2271 and J2275.
05/22/2020: Code Reference section updated to remove deleted CPT codes 62310, 62311, 62318, and 62319.
10/14/2022: Policy reviewed; no changes.
10/18/2023: Policy reviewed. Policy statements unchanged. Sources updated.
12/03/2024: Policy reviewed; no changes.
Portenoy, R. K. (n.d.). Cancer pain management: Interventional therapies. UpToDate. https://www.uptodate.com/contents/cancer-pain-management-interventional-therapies?search=intraventricular+morphine&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H73805433 . Accessed September 2023.
This may not be a comprehensive list of procedure codes applicable to this policy.The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Code Number | Description | ||
CPT-4 | |||
62320 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance | ||
62321 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) | ||
62322 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance | ||
62323 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) | ||
62324 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance | ||
62325 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) | ||
62326 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance | ||
62327 | Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) | ||
62350 | Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy | ||
62351 | Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy | ||
62355 | Removal of previously implanted intrathecal or epidural catheter | ||
62360 | Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir | ||
62362 | Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming | ||
62365 | Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion | ||
62367 | Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming | ||
62368 | Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming | ||
95990 | Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular) Note: The refill and maintenance of an intraventricular pump or reservoir is not covered. | ||
99551 | Home infusion for pain management (intravenous or subcutaneous), per visit | ||
99552 | Home infusion for pain management (epidural or intrathecal), per visit | ||
HCPCS | |||
A4300 | Implantable access catheter, (e.g., venous, arterial, epidural subarachnoid, or peritoneal, etc.) external access | ||
A4301 | Implantable access total catheter, port/reservoir (e.g., venous, arterial, epidural, subarachnoid, peritoneal, etc.) | ||
E0779 | Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater | ||
E0780 | Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours | ||
E0781 | Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient | ||
E0785 | Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement | ||
E0786 | Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) | ||
J2270 | Injection, morphine sulfate, up to 10 mg | ||
S0093 | Injection, morphine sulfate, 500 mg (loading dose for infusion pump) | ||
ICD-9 Procedure | ICD-10 Procedure | ||
03.90 | Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances | 00HU03Z, 00HU33Z, 00HU43Z | Insertion of infusion device into spinal canal, by approach |
00HV03Z, 00HV33Z, 00HV43Z | Insertion of infusion device into spinal cord, open approach | ||
03.92 | Injection of other agent into spinal canal | 3E0R3NZ | Introduction of analgesics, hypnotics, sedatives into spinal canal, percutaneous approach |
3E0S3NZ | Introduction of analgesics, hypnotics, sedatives into epidural space, percutaneous approach | ||
86.06 | Insertion of totally implantable infusion pump | 0JHT0VZ, 0JHT3VZ, 0JH60VZ, 0JH63VZ, 0JH70VZ, 0JH73VZ, 0JH80VZ, 0JH83VZ | Insertion of infusion pump, by specific area, subcutaneous tissue and fasia, by approach |
ICD-9 Diagnosis | ICD-10 Diagnosis |
Investigational Codes
Code Number | Description | ||
CPT-4 | |||
61026 | Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment | ||
61215 | Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter | ||
HCPCS | |||
ICD-9 Procedure | ICD-10 Procedure | ||
01.02 | Ventriculopuncture through previously implanted catheter | 8C01X6J | Collection of cerebrospinal fluid from indwelling device in nervous system |
ICD-9 Diagnosis | ICD-10 Diagnosis |
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