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

By 2026-03-31: Billing team must implement the following in claims processing and prior authorization workflows: (1) For all infusion pump claims, verify in patient charts that the prescribed medication is FDA-approved for infusion pump use and that the patient meets ALL medical necessity criteria specific to the pump type (intrathecal baclofen, intraspinal opioids, external chemotherapy/insulin, etc.); (2) For intrathecal baclofen pumps, confirm documentation of failed trial of oral anti-spasmodics (or exemption for patients ≤12 years old), favorable response to intrathecal trial dose, and 100 mcg bolus response; (3) For chronic pain infusion pumps, verify 50% pain reduction on preliminary trial and psychological evaluation for non-malignant pain cases; (4) For external insulin pumps, confirm patient is on ≥3 daily injections with documented HbA1c >7% or hypoglycemia history, completed diabetes education, and ≥4 daily glucose tests or CGM use for 2 months; (5) Screen all claims for contraindications (active infection, insufficient body size, drug allergy, device crosstalk); (6) Update prior authorization templates to require these specific clinical criteria and documentation before approval. Providers must attach supporting clinical documentation with all pump claims. Failure to verify these criteria will result in claim denials and rework.