Medicare AdvantageCoverageMedium impact
Implantable Infusion Pumps for Pain or Spasticity - Medicare Advantage (Revised)
Humana·Pain Management, Neurology, Neurosurgery +2 more·Pharmacy
Effective date
Jul 1, 2025
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has revised their policy for implantable infusion pumps used for pain or spasticity management, establishing specific medical necessity criteria including temporary trial requirements and success metrics. The policy provides detailed coverage determination guidelines for both antispasmodic drugs for severe spasticity and drugs for severe intractable pain treatment.
Action Required
By July 1, 2025: Billing team must update prior authorization requirements for implantable infusion pump procedures to include documented temporary trial results, baseline Ashworth scores of at least 3 for spasticity cases, and evidence of 6-week failed conservative treatment. Providers must document FDA-approved drug usage and absence of contraindications. Update encounter forms to capture required medical necessity criteria as claims may be denied without proper documentation.