← Back to list
Implantable and External Infusion Pumps for Pain or Spasticity - Medicare Advantage (Revised)
Effective date
Jul 1, 2026
Identified
Jun 30, 2026
Summary
This revised Medicare Advantage policy (effective 07/01/2026) establishes specific clinical criteria for implantable and external infusion pumps for pain and spasticity management. Key changes include: requiring a baseline Modified Ashworth Scale score of ≥3 for baclofen trials, mandating a 2-point MAS reduction for permanent implantation, and defining 'failure of conservative therapy' requirements with a 50% pain reduction threshold for opioid/non-opioid trials. The policy also clarifies replacement/revision criteria and addresses postoperative external pumps.
Get alerts when payers change rules like this one
We check Humana and other payers every day and email you when a change matches your specialty and state.
Get Humana alertsPolicy Monitoring is free. No card required.
What to do
Action · 7 steps
01By 06/01/2026: Billing and clinical teams must update prior authorization protocols and medical necessity documentation requirements.
02Modify PA templates to require: baseline MAS score ≥3 for intrathecal baclofen trials (CPT 62322-62327, C2626); documented failure of conservative therapy for pain management trials; and 50% pain reduction confirmation for permanent pain pump implantations.
03Update provider encounter forms and clinical notes to capture Modified Ashworth Scale scores pre- and post-trial.
04Train coding staff on geographic MAC jurisdictions (DME MACs A-D and Part A/B MACs JE, JF, JJ, JM) and ensure correct LCD application per state.
05Review existing pending claims for spasticity/pain pump procedures and re-submit with updated MAS documentation if previously lacking.
06Coordinate with providers to ensure trial data collection and documentation of clinical outcomes before requesting permanent implant authorization.
07Non-compliance will result in claim denials for insufficient documentation of severity metrics and trial success thresholds.
Codes mentioned
62322623236232462325623266232762350623516235562360623616236262365C1772C1891C2626E0782E0783E0785E0786
Original notice
Implantable and External Infusion Pumps for Pain or Spasticity - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
Related changes
See all Humana changes →Implantable Infusion Pumps for Pain or Spasticity - Medicare Advantage (Revised)MediumEffective Jul 1, 2025 · PharmacyInjections for Chronic Pain Conditions - MEDICAID - OKLAHOMA (Revised)HighEffective Jul 29, 2026 · MedicaidInjections for Chronic Pain Conditions - MEDICAID - KENTUCKY (Revised)HighEffective Jul 15, 2026 · MedicaidInjections for Chronic Pain Conditions - MEDICAID - OKLAHOMA (New)HighEffective Jan 7, 2026 · MedicaidBrowse every Humana change in the policy list