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AetnaAll Plans · Coverage · Pharmacy · Endocrinology, Neurology, Pain Management +2 moreMedium impact

Infusion Pumps (CPB 0161, reviewed 2026-03-31)

Effective date
Not stated in the notice
Identified
Aug 19, 2026

Summary

Aetna Clinical Policy Bulletin 0161 sets the medical necessity criteria for implantable infusion pumps, including intrathecal baclofen for severe spasticity of cerebral or spinal origin, intrathecal or epidural opioids, ziconotide and clonidine for severe chronic intractable pain, and intrahepatic chemotherapy for primary hepatocellular carcinoma and for colorectal cancer metastases limited to the liver. It also covers external infusion pumps for listed drugs, including certain chemotherapy, antifungal and antiviral drugs, heparin, deferoxamine, morphine for intractable cancer pain, and insulin for members with diabetes who meet the stated criteria, and it lists the CPT, HCPCS and ICD-10 codes that are covered when criteria are met and those not covered for the listed indications.

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What to do

Action · 8 steps
01Before a claim is submitted for an item in this policy, a Standard Written Order must be communicated to the supplier.
02If the supplier bills for an item without first receiving a completed SWO, the claim will be denied as not medically necessary.
03The SWO must include the member's name or identification number, the order date, a general description of the item (HCPCS code, HCPCS narrative, or brand name and model number), each concurrently ordered option, accessory or supply listed separately, the HCPCS code and quantity for each item, the treating practitioner's name and NPI, and the treating practitioner's signature.
04A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.
05The medical record must contain information that supports medical necessity and substantiates any supplier-prepared statement or practitioner attestation, because those alone do not provide sufficient documentation.
06Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not sufficient by themselves.
07Continued medical necessity of an external insulin pump requires that the member be seen and evaluated by the treating physician at least once every 6 months.
08HCPCS codes J0735, J2270 and J2278 are not covered in combination with baclofen, and HCPCS codes J1811, J1813 and J1817 are listed as not covered for the indications in the policy.

Codes mentioned

3656336576365783658336590623659652196522A4220A4221C1772C1891C2626E0779E0780E0781E0782E0783E0784E0787J0475J0476J0735J0895J1644J1811J1813J1817J2260J2270J2278S9328S9353C22.0G25.82Z79.4

Original notice

Infusion Pumps (CPB 0161, reviewed 2026-03-31)
aetna.com · Always check the source before changing claims.
View original ↗

Related changes

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Ziconotide (Prialt) (CPB 0712, reviewed 2026-10-14)MediumNo effective date · Medical PolicyZiconotide (Prialt) (CPB 0712, reviewed 2026-03-11)MediumNo effective date · Medical PolicyAnesthetic and Antiemetic Infusion Pumps (CPB 0607, reviewed 2026-09-09)MediumNo effective date · PharmacyAnesthetic and Antiemetic Infusion Pumps (CPB 0607, reviewed 2026-02-25)MediumNo effective date · PharmacyBrowse every Aetna change in the policy list

Related policy hubs

Aetna policiesEndocrinologyNeurologyPain ManagementOncologyOrthopedicsCode 36563Code 36576Code 36578Code 36583Code 36590Code 62365Code 96521Code 96522Code A4220Code A4221Code C1772Code C1891Code C2626Code E0779Code E0780Code E0781Code E0782Code E0783Code E0784Code E0787Code J0475Code J0476Code J0735Code J0895Code J1644Code J1811Code J1813Code J1817Code J2260Code J2270Code J2278Code S9328Code S9353Code C22.0Code G25.82Code Z79.4

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