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AetnaCommercial · Coverage · Medical Policy · Pain Management, Neurology, OncologyMedium impact

Ziconotide (Prialt) (CPB 0712, reviewed 2026-03-11)

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

Summary

Intrathecal ziconotide (Prialt) is considered medically necessary for members with severe chronic pain that is intolerant of or refractory to other treatments, such as systemic analgesics, adjunctive therapies, or intrathecal morphine. It is considered not medically necessary for members with a pre-existing history of psychosis, an infection at the micro-infusion injection site, uncontrolled bleeding diathesis, or spinal canal obstruction. Use for autism, epilepsy, Irukandji syndrome, migraines, primary lateral sclerosis, and stroke is considered experimental, investigational, or unproven, as is the intrathecal combination of ziconotide, morphine, and levobupivacaine for cancer-related refractory pain.

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What to do

Action · 7 steps
01Claims for ziconotide (J2278, 1 mcg) need documentation that the member has severe chronic pain that is intolerant of or refractory to other treatments, such as systemic analgesics, adjunctive therapies, or intrathecal morphine.
02The policy lists ICD-10 codes G89.0 through G89.4 (pain, not elsewhere classified) as covered when the selection criteria are met.
03Ziconotide is not medically necessary for members with a pre-existing history of psychosis, or where there is an infection at the micro-infusion injection site, uncontrolled bleeding diathesis, or spinal canal obstruction.
04The policy lists these ICD-10 codes as not covered: C72.0 (spinal canal obstruction), D33.4 (spinal canal obstruction), D69.9 (uncontrolled bleeding diathesis), F23, F24, F28, F29 (psychosis), F84.0 (autism), G12.23 (primary lateral sclerosis), G89.3 (neoplasm related pain), and Z86.59 (pre-existing history of psychosis).
05Pump codes listed in the policy are E0779, E0780, E0781, E0783, E0785, and E0786.
06C9811 must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the CAA, 2023.
07Morphine codes J2270, J2272, and S0093 are listed as related codes.

Codes mentioned

J2278C9811E0779E0780E0781E0783E0785E0786J2270J2272S0093C72.0D33.4D69.9F23F24F28F29F84.0G12.23Z86.59G89.3

Original notice

Ziconotide (Prialt) (CPB 0712, reviewed 2026-03-11)
aetna.com · Always check the source before changing claims.
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Related changes

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Related policy hubs

Aetna policiesPain ManagementNeurologyOncologyCode J2278Code C9811Code E0779Code E0780Code E0781Code E0783Code E0785Code E0786Code J2270Code J2272Code S0093Code C72.0Code D33.4Code D69.9Code F23Code F24Code F28Code F29Code F84.0Code G12.23Code Z86.59Code G89.3

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