Does S9353 require prior authorization?

No, S9353 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for S9353?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`S9353`, Home infusion therapy, continuous insulin infusion therapy; administrative

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For intrathecal baclofen: 'The patient should be shown to respond to a single intrathecal bolus dose of up to 100 mcgs of baclofen. A positive response is defined as an average two-point drop on an objective muscle tone or spasm screening system (e.g., The Ashworth and Spasm scale).'
Pre-implantation requirements for spinal analgesia: 'To be considered for spinal analgesia, a patient must have a normal platelet count and no coagulation disorder, infection, or other problems that might preclude the use of spinal drugs.'

Intrahepatic chemotherapy: documentation supporting diagnosis of primary hepatocellular carcinoma or metastatic colorectal cancer limited to the liver and clinical justification for intrahepatic infusion.

Trialing before permanent intrathecal pump implantation: 'Before the implantation of a permanent infusion system, an efficacy test is usually performed to assess the patient's response and dose. One or several trial doses of 5 to 10 mg of epidural morphine, or 0.5 to 1.0 mg intrathecal morphine is/are administered while all other analgesic medications are stopped. Subjective pain ratings and undesirable side effects are evaluated for several days.'

Observation after trialing: professional guidance (PACC) 'strongly recommend at least 24-hour inpatient observation for trialing.' (cited Wilkes 2014 and UCSF guidance).

For intrathecal opioid pump implantation: documentation that pain was 'markedly reduced' during trialing and that other opioid analgesics are not needed.

Key Coverage Criteria

G89.4 Chronic pain syndrome
G95.11 - G95.19 Vascular myelopathies
O88.011 - O88.83 Obstetric embolism
External infusion pumps (only) for deferoxamine for treatment of acute iron poisoning and iron overload.
G82.50 - G82.54 Quadriplegia
Implanted infusion pumps are medically necessary durable medical equipment (DME) when: the drug is medically necessary for the treatment of the member; it is medically necessary that the drug be administered by an implanted infusion pump; and the infusion pump has been approved by the FDA for infusion of the particular drug that is to be administered.

3 Active Policies

ANTHEM-CG-MED-23, Home Health

AETNA-CPB-0161, Infusion Pumps

AMBETTER-CP.MP.91, Obstetrical Home Care Programs

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S9353, Home infusion therapy, continuous insulin infusion therapy; administrative