Clinical Policy Title: Intrathecal opioid therapy for chronic pain

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1 Clinical Policy Title: Intrathecal opioid therapy for chronic pain Clinical Policy Number: Effective Date: October 1, 2014 Initial Review Date: March 19, 2014 Most Recent Review Date: February 6, 2018 Next Review Date: February 2019 Policy contains: Implantable drug infusion pump. Morphine sulfate. Chronic pain. Related policies: CP# CP# CP# CP# CP# Biofeedback for chronic pain Spine pain epidural steroid injections Spine pain facet joint injections Spine pain trigger point injections Hierarchy of chronic pain management ABOUT THIS POLICY: Prestige Health Choice has developed clinical policies to assist with making coverage determinations. Prestige Health Choice s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Prestige Health Choice when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Prestige Health Choice s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Prestige Health Choice s clinical policies are reflective of evidencebased medicine at the time of review. As medical science evolves, Prestige Health Choice will update its clinical policies as necessary. Prestige Health Choice s clinical policies are not guarantees of payment. Coverage policy Prestige Health Choice considers the use of intrathecal opioid therapy for chronic pain to be clinically proven and, therefore, medically necessary when the following criteria are met (American Medical Association [AMA], LCD 33461; Deer, 2017a; Deer, 2017b; Deer, 2017c): Severe chronic intractable pain. Demonstrated unresponsiveness to other methods of pain control (pharmacologic, surgical, psychological, or physical) by a specialist familiar with the underlying disease, if appropriate and not contraindicated, including attempts to eliminate physical and behavioral abnormalities which may cause an exaggerated reaction to pain. No contraindications to implantation, such as sepsis or coagulopathy. No contraindications to opioid therapy. 1

2 Ability to comply with the medication refill schedule. Body size sufficient to support the weight and bulk of the device. Therapy furnished in a setting appropriate to the patient's medical needs and condition. A preliminary trial of intraspinal opioid drug administration undertaken with a temporary intrathecal catheter to substantiate adequately acceptable pain relief, degree of side effects (including effects on the activities of daily living), and patient acceptance. Use of an implantable infusion pump that is U.S. Food and Drug Administration (FDA)-approved for use with preservative-free morphine sulfate for treatment of chronic pain. Prestige Health Choice considers revision, replacement, or removal of implantable infusion pumps for administration of intrathecal opioid therapy to be medically necessary when the member meets the above candidate criteria and the device has malfunctioned (which may involve upgrading to the most current technology). Limitations: Coverage determinations are subject to benefit limitations and exclusions as delineated by the state Medicaid authority. The Florida Medicaid website may be accessed at The cause of the pain should be distinguished between pain due to a terminal diagnosis caused by a malignancy and pain due to non-malignant conditions of longer term (AMA, LCD ID L35112). In terminal malignant conditions, the shift from a non-invasive pain control modality to a more invasive method of administration, including the use of an implanted pump, may take place more quickly with less emphasis on patient-level behavioral approaches to pain control. The AMA specifies that an implanted infusion pump for chronic pain is eligible for Medicare coverage when used to intrathecally administer opioids, either singly or combined with other opioid or non-opioid medication, for addressing severe chronic resistant pain of malignant or nonmalignant origin in patients who have a life expectancy of a minimum of three months and in whom there has been inadequate response to less invasive medical therapy. To be considered medically reasonable and necessary, each of the following criteria must be met: The administration of the medication must require administration through the intrathecal route and be effective on a long-term basis. The history of the patient's prior treatment should show oral or subcutaneous medication treatment was ineffective or complicated by unacceptable side effects. The patient's medical condition must require the use of an infusion pump for pain relief. The type and dosage of the medication must reasonably be expected to alleviate or reduce the pain (AMA, LCD ID L35112; LCD ID L33593). 2

3 Intrathecal delivery of morphine in combination with other analgesics is not clinically proven and, therefore, not medically necessary. Replacement or upgrade of an implantable intrathecal infusion pump is not medically necessary when requested for convenience or to upgrade to newer technology when the current components remain functional. When an implantable intrathecal infusion pump is determined to be medically necessary, the refill kits and supplies necessary for the proper use of the pump are considered medically necessary and, therefore, not eligible for separate reimbursement consideration. Alternative covered services: Pharmacological treatment. Physical treatment (occupational therapy and physiotherapy). Behavioral and psychological treatments. Surgical treatment. Background The International Association for the Study of Pain (IASP) defines chronic pain as pain persisting beyond normal tissue healing time (IASP, 1986). Chronic pain is a major burden and an expensive health problem in industrialized countries. The cause of chronic pain can be malignant or nonmalignant, with the latter accounting for the vast majority of patients. Chronic low back pain is the most prevalent chronic nonmalignant pain (Chou, 2009). Conventional management of chronic pain mainly involves eliminating the underlying cause and providing pharmacological treatment, physical treatment (occupational therapy and physiotherapy), or other treatments (psychotherapy and integrative therapies). Opioid therapy may be a useful component of the management plan. The selection of patients for an opioid trial, and decisions about chronic opioid therapy, will depend on weighing the potential benefits of opioids against the risk of significant harms, including a wide range of adverse effects and adverse outcomes associated with potential abuse (Chou, 2009). Intrathecal drug delivery: Intrathecal drug delivery systems (i.e. pumps) have become widely used over the past two decades to treat severe chronic intractable pain of malignant or nonmalignant origin. Nonmalignant chronic pain indications have been reported, including neuropathy, mixed neuropathic-nociceptive pain, radicular pain due to failed back syndrome, and complex regional pain syndrome, although no standard guidelines exist. Medications may be delivered in this manner to minimize the side effects often associated with the higher doses used in systemic delivery of these drugs. Intrathecal pumps are considered when conventional treatments fail to relieve pain or cause intolerable side effects (Hayek, 2011). 3

4 The intrathecal pump consists of a device for storing and delivering the medication and a catheter inserted surgically into the intrathecal space in the spine where the medication takes effect. Intrathecal pumps may be nonprogrammable or programmable. A surgeon typically performs a trial of intrathecal injections or implants a temporary intrathecal pump, which is replaced by a permanent intrathecal pump if there is acceptable pain relief, degree of side effects, and patient acceptance. Considerations for choosing the pump site placement include the following: The pump should not be placed where restrictive clothing, the belt line, braces, orthotics, and/or the sides of a wheelchair will irritate it. For a patient who is scheduled for or already receiving radiation therapy, the pump site should preferably not overlie the radiation site. The pump should be no more than 2.5 cm from the surface of the skin. Regulatory status: The FDA approved several implantable programmable and nonprogrammable infusion pumps as Class III devices for continuous intrathecal administration of opioid drug therapy (premarket approval [PMA] product code LKK) (FDA, 2017a). Preservative-free morphine sulfate is the only opioid approved by the FDA for intrathecal delivery to treat chronic pain at a maximum approved concentration of 25 mg/ml and only as monotherapy; intrathecal morphine used in combination with other drugs is considered an off-label use (FDA, 2017b). Searches Prestige Health Choice searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on January 3, Search terms were: Injections, Spinal (MeSH), Analgesics, Opioid (MeSH), and the free-text terms intrathecal and opioid. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. 4

5 Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings Several systematic reviews of intrathecal opioid therapy published since 2006 were identified for this policy. This policy included only the most recent systematic reviews published since 2010, as they reflected the most current literature to date. Also included were: 1) a health technology assessment from the Institut National d'excellence en Sante et en Services Sociaux (INESSS) in Quebec, Canada, which highlighted important considerations for implementation; and 2) one recent cost-effectiveness analysis, as well as findings of cost-effectiveness from the systematic reviews. All systematic reviews found evidence from a limited number of observational studies that evaluated the safety and effectiveness of intrathecal opioid therapy for chronic nonmalignant pain; no high-quality evidence from randomized controlled trials (RCTs) was identified. Across studies there was significant variability in study design, patient selection, concomitant oral or transdermal opioid use, pain measures and definitions of effectiveness, follow-up, and technical parameters that may have important effects on outcomes of intrathecal therapies. There is insufficient information for adequate comparison to other routes of delivery, or on long-term effectiveness of chronic opioid therapy in this population. The limited evidence suggests that intrathecal opioids delivered via implantable programmable infusion pumps can provide effective but variable pain relief and improve quality of life in a select group of patients with chronic, intractable, nonmalignant pain who have failed conventional pain management. Data are lacking on the effectiveness of intrathecal combination drug therapy. It is currently unknown if combination therapy is superior to monotherapy. Complications related to intrathecal therapy can be technical, biological, or medication-related. Drugrelated adverse effects are mostly transient and well-tolerated. Device-related complications and need for surgical revision appear to have occurred at a higher rate in earlier publications; the lower rates in more recent publications may reflect improved education, techniques, and experience in the implanting providers. Chronic infusions of intrathecal opioids are associated with the formation of inflammatory masses at the intrathecal catheter tip in a small minority of treated patients, and their presence can lead to significant neurologic sequelae. Prevention, early detection, and successful treatment of intraspinal granulomas are important considerations when offering intrathecal drug therapy to patients with chronic intractable pain. Economic analyses suggest that cost savings are achieved after two years of use of intrathecal administration compared with systemic pharmacologic therapy for chronic, nonmalignant pain. While this may help justify the initial costs of an implantable pump system, given the life of a programmable pump and associated high replacement costs, maintaining this treatment option beyond the initial life of the 5

6 pump over the patient s life span will require close monitoring to ensure the patient achieves optimal treatment effectiveness. Current evidence-based guidelines acknowledge the evidence to support intrathecal drug delivery of opioids for nonmalignant pain is less robust than the evidence for cancer pain (Chou, 2009; American Society of Regional Anesthesia and Pain Medicine [ASRAPM], 2010; Deer, 2010; Hooten, 2013; Manchikanti, 2013; Abdulla, 2013). In the absence of rigorous data, a consensus guideline panel recommended multidisciplinary patient selection criteria to identify in whom and when to implant intrathecal opioid therapy pumps (Deer, 2010): Chronic pain results in significant interference with activities of daily living, including ability to work, and overall quality of life. Chronic pain is recalcitrant to conservative medical or surgical therapy. Preexisting medical comorbidities are well controlled, and appropriate disease-specific guidelines are followed pre- and post-implantation. Patients are not at high risk for infection or presenting with an active infection. Patients can comply with the medication refill schedule. Patients present without any severe or uncontrolled psychological conditions. Opioid therapy is not contraindicated (e.g., a patient who has difficulties managing their medications, an individual with certain comorbid conditions in which oral opioids have the potential for severe adverse effects). Additional data from RCTs is needed to complement current evidence from observational studies and clarify the optimal patient selection in intrathecal opioid therapy in patients with chronic nonmalignant pain. Falco (2013) encouraged use of equivalence or noninferiority trials with randomization but without blinding. Until these data become available, consensus-based guidelines may assist providers in patient selection for intrathecal opioid therapy that will help optimize outcomes. Policy updates: In 2015, Prestige Health Choice identified one new guideline by Prager (2014) that identified best practices and provided guidance to clinicians to ensure safety and optimize intrathecal drug delivery for chronic intractable pain. These findings do not contradict the original findings of this policy; therefore, no changes to the policy are warranted. A new health technology assessment from Health Quality Ontario (2016) evaluated the comparative effectiveness, harms, and cost-effectiveness of intrathecal drug delivery of opioids for chronic nonmalignant pain compared to oral administration or rehabilitation. The evidence continues to be of low quality. While intrathecal delivery resulted in some pain relief, it did not translate into improved quality of life or patient-reported well-being. Current evidence does not rule in or rule out superiority or costeffectiveness of intrathecal drug delivery systems for managing chronic refractory nonmalignant pain. These results are consistent with previous findings. No policy changes are warranted. 6

7 In January 2018, we identified four new guidelines and updated National and Local Coverage Determinations. The Hooten guidelines published by the Institute for Clinical Systems Improvement (2016) update a 2013 publication. They provide general assessment and management recommendations, but do not discuss intrathecal treatment. The Polyanalgesic Consensus Conference, organized by the International Neuromodulation Society, published an update of their recommendations for best practices and guidelines for intrathecal therapies (Deer, 2017a). This publication recommended intrathecal opioid therapy for active cancer-related pain (Evidence Level I, Recommendation Grade A, Consensus Level Strong) and for noncancer-related pain (Evidence Level III, Recommendation Grade B, Consensus Level Strong). Intrathecal therapy with ziconotide was recommended for both cancer-related and non-cancer-related pain (Evidence Level I, Recommendation Grade A, Consensus Level Strong). Two other publications stemming from the same conference provide recommendations for enhancing safety and mitigating risks, and for testing or trialing intrathecal therapy before implantation (Deer, 2017b; 2017c). Summary of clinical evidence: Citation Health Quality Ontario (2016) Intrathecal drug delivery systems for non-cancer pain INESSS (2013) on behalf of Quebec Province Intrathecal pumps for the treatment of chronic non-cancer pain Content, Methods, Recommendations Key points: Health technology assessment included four systematic reviews, one prospective cohort study, and one retrospective study for evidence of effectiveness and harms, and four economic evaluations of intrathecal drug delivery systems, all versus standard care (Biggs, 2011; de Lissovoy, 1997; Kumar, 2002; Kumar, 2013; Thimineur, 2004; Doleys, 2006; see references). Overall quality: very low. Patients had lower pain scores with intrathecal drug delivery systems but did not seem to feel pain less or to be happier with treatment compared with patients who received only oral opioids or a rehabilitation program. No studies compared problems with intrathecal drug delivery systems and routine care. No reliable estimates of cost-effectiveness were found. From the perspective of the Ontario Ministry of Health and Long-Term Care, the annual budget impact of publicly funding intrathecal drug delivery for this population would be between $1.5 and $5.0 million per year; much uncertainty in the calculations. Key points: Health technology assessment based on five systematic reviews or meta-analyses (Hayek, 2011; Patel, 2009; Noble, 2008, Noble, 2010; Turner, 2007; see references), two cohort studies, and a regional cost analysis. Quality assessment: low; no RCTs found. Effective for pain relief in patients with chronic noncancer pain that is nociceptive, mixed, or neuropathic in origin. Complications related to the devices and medications exist. Program requirements: - Patient selection, management, and follow-up by a multidisciplinary team composed of at least a neurosurgeon, anesthesiologist, psychologist, and nursing care professional. - Psychological assessment and a stimulation test lasting at least one week. - Intrathecal pumps must be implanted in chronic pain management centers. 7

8 Citation Falco (2013) Content, Methods, Recommendations Economic analysis for Quebec showed cost effectiveness in favor of the intervention. Future analyses will need to account for increase in equitable access to services and postimplantation as population ages and costs predictably increase due to technological advances. Key points: Intrathecal infusion systems for longterm management of chronic noncancer pain Systematic review of seven observational studies (767 total patients) for short- and long-term chronic noncancer pain management. Quality assessment: moderate for all observational studies. Limited evidence for short-term and long-term pain relief and functional improvement. Independent, transparent, and unbiased research is needed to clarify patient selection criteria. Authors encouraged use of equivalence or noninferiority trials with randomization, but without blinding. Current specific patient selection indications are not evidence-based. In their absence, authors recommended consensus guidelines. References Professional society guidelines/other: Abdulla A, Adams N, Bone M, et al. Guidance on the management of pain in older people. Age Ageing Mar; 42 Suppl 1: i1-57. Doi: /ageing/afs200. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. (ASRAPM) Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology Apr; 112(4): Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain Feb; 10(2): Deer TR, Smith HS, Cousins M, et al. Consensus guidelines for the selection and implantation of patients with noncancer pain for intrathecal drug delivery. Pain Physician May-Jun; 13(3): E Deer, T. R., Pope, JM, Hayek SM, et al. The Polyanalgesic Consensus Conference (PACC): Recommendations for intrathecal drug delivery: guidance for improving safety and mitigating risks. Neuromodulation. 2017b;20: Doi: /ner Deer TR, Hayek SM, Pope JE, et al. The Polyanalgesic Consensus Conference (PACC): Recommendations for trialing of intrathecal drug delivery infusion therapy. Neuromodulation. 2017c;20(2): Doi: /ner

9 Deer TR., Pope JE, Hayek SM, et al. The Polyanalgesic Consensus Conference (PACC): Recommendations on intrathecal drug infusion systems best practices and guidelines. Neuromodulation. 2017a;20: Doi: /ner Hooten M, Thorson D, Bianco J, et al. Pain: assessment, non-opioid treatment approaches and opioid management. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2016 Sep. National Guideline Clearinghouse website. Accessed January 3, Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician Apr; 16(2 Suppl): S PMID: Peer-reviewed references: Biggs SA, Duarte RV, Raphael JH, Ashford RL. Influence of a latent period in QALY analysis: pilot study of intrathecal drug delivery systems for chronic non-malignant pain. Br J Neurosurg. 2011; 25(3): Doi: / de Lissovoy G, Brown RE, Halpern M, Hassenbusch SJ, Ross E. Cost-effectiveness of long-term intrathecal morphine therapy for pain associated with failed back surgery syndrome. Clin Ther. 1997; 19(1): ; discussion Doleys DM, Brown JL, Ness T. Multidimensional outcomes analysis of intrathecal, oral opioid, and behavioral-functional restoration therapy for failed back surgery syndrome: A retrospective study with 4 years' follow-up. Neuromodulation. 2006; 9(4): Doi: /j x. Falco FJ, Patel VB, Hayek SM, et al. Intrathecal infusion systems for long-term management of chronic noncancer pain: an update of assessment of evidence. Pain Physician Apr; 16(2 Suppl): SE PMID: Hayek SM, Deer TR, Pope JE, Panchal SJ, Patel VB. Intrathecal therapy for cancer and non-cancer pain. Pain Physician May-Jun; 14(3): PMID: Health Quality Ontario. Intrathecal drug delivery systems for noncancer pain: A health technology assessment. Ont Health Technol Assess Ser. 2016; 16(2): PMCID: PMC IASP. Classification of Chronic Pain Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. Second ed. H. Merskey and N. Bogduk, editors. Seattle: International Association for the Study of Pain Task Force on Taxonomy; Available at: Accessed January 3,

10 Institut national d'excellence en sante et en services sociaux (INESSS). Utilisation des pompes intrathécales dans le traitement de la douleur chronique non cancéreuse [Use of intrathecal pumps for the treatment of chronic non-cancer pain]: efficacité, innocuité, indications cliniques, modalités organisationnelles et coûts. Rapport rédigé par Alvine Fansi et Christine Lobè. ETMIS 2013; 9(4): [English abstract]. Quebec. INESSS website. r_chronique_noncancere.pdf. Accessed January 3, Kumar K, Hunter G, Demeria DD. Treatment of chronic pain by using intrathecal drug therapy compared with conventional pain therapies: a cost-effectiveness analysis. J Neurosurg. 2002; 97(4): Kumar K, Rizvi S, Bishop S. Cost effectiveness of intrathecal drug therapy in management of chronic nonmalignant pain. Clin J Pain Feb; 29(2): Doi: /AJP.0b013e31824b5fc9. Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010(1): Cd Doi: / Noble M, Tregear SJ, Treadwell JR, Schoelles K. Long-term opioid therapy for chronic noncancer pain: a systematic review and meta-analysis of efficacy and safety. J Pain Symptom Manage Feb; 35(2): Doi: /j.jpainsymman Thimineur MA, Kravitz E, Vodapally MS. Intrathecal opioid treatment for chronic non-malignant pain: a 3- year prospective study. Pain. 2004; 109(3): Turner JA, Sears JM, Loeser JD. Programmable intrathecal opioid delivery systems for chronic noncancer pain: a systematic review of effectiveness and complications. Clin J Pain Feb; 23(2): Doi: /01.ajp U.S. Food and Drug Administration. FDA Pre-Market Approval Database. Available at: Searched product code LKK on January 3, 2018.(a) U.S. Food and Drug Administration. PRESERVATIVE-FREE DURAMORPH (morphine sulfate injection, USP). Product label. Available at: Accessed January 3, 2018.(b) CMS National Coverage Determination (NCDs): Infusion Pumps. CMS website. Accessed January 3, Local Coverage Determinations (LCDs): 10

11 L35112 Implantable Infusion Pump. CMS website. Accessed January 3, L33461 Implantable Infusion Pump. CMS website. Accessed January 3, L33593 Implantable Infusion Pump for the Treatment of Chronic Intractable Pain. CMS website. Accessed January 3, 2018 Local coverage article: A54649 Implantable Infusion Pump for the Treatment of Chronic Intractable Pain coding guidelines. CMS website. Accessed January 3, Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comments Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy Removal of previously implanted intrathecal or epidural catheter Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming. 11

12 CPT Code Description Comments Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill (requiring skill of a physician or other qualified health care Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care. ICD-10 Code Description Comments G56.40-G56.43x Causalgia of upper limb. G60.9 Hereditary and idiopathic neuropathy, unspecified. G89.21-G89.4x G90.50-G90.59x G95.21-G95.90 Chronic pain, not elsewhere classified. Complex regional pain syndrome I (CRPS I). Unspecified cord compression. G95.29 Other cord compression. G95.9 Disease of the spinal cord, unspecified. M25.50-M25.579x M50.00-M50.93x M51.04-M51.9x M53.0-M53.9x M54.00-M54.9x Pain in joint. Cervical disc disorders. Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders. Other and unspecified dorsopathies, not elsewhere classified. Dorsalgia. M965.1 Post laminectomy syndrome, not elsewhere specified. M98.2x-M98.7x S14.2XXA S24.2XXA S34.21XA S34.22XA Subluxation stenosis of neural canal - Connective tissue and disc stenosis of intervertebral foramina. Injury of nerve root of cervical spine, initial encounter. Injury of nerve root of thoracic spine, initial encounter. Injury of nerve root of lumbar spine, initial encounter. Injury of nerve root of sacral spine, initial encounter. HCPCS Level II Code E0782 E0785 Description Non-programmable infusion pump. Replacement implantable pump catheter. Comments 12