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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that: 
A. General 
Infusion pumps are medical devices used to deliver solutions containing parenteral drugs under pressure at a 
regulated flow rate. 
B. Nationally Covered Indications 
Implantable Infusion Pumps 
a.     Chemotherapy for Liver Cancer (Effective for Services Performed On or After September 26, 1984) 
The implantable infusion pump is covered for intra-arterial infusion of 5-FUdR for the treatment of liver cancer 
for patients with primary hepatocellular carcinoma or Duke's Class D colorectal cancer, in whom the 
metastases are limited to the liver, and where: (1) the disease is unresectable, or, (2) the patient refuses surgical 
excision of the tumor. 
b.     Anti-Spasmodic Drugs for Severe Spasticity 
An implantable infusion pump is covered when used to administer anti-spasmodic drugs intrathecally (e.g., 
baclofen) to treat chronic intractable spasticity in patients who have proven unresponsive to less invasive 
medical therapy as determined by the following criteria: 
As indicated by at least a 6-week trial, the patient cannot be maintained on non-invasive methods of spasm 
control, such as oral anti-spasmodic drugs, either because these methods fail to control adequately the spasticity 
or produce intolerable side effects. And prior to pump implantation, the patient must have responded favorably 
to a trial intrathecal dose of the anti-spasmodic drug. c.     Opioid Drugs for Treatment of Chronic Intractable Pain 
An implantable infusion pump is covered when used to administer opioid drugs (e.g., morphine) intrathecally 
or epidurally for treatment of severe chronic intractable pain of malignant or nonmalignant origin in patients 
who have a life expectancy of at least 3 months, and who have proven unresponsive to less invasive medical 
therapy as determined by the following criteria: 
The patient's history must indicate that he/she would not respond adequately to noninvasive methods of pain 
control, such as systemic opioids (including attempts to eliminate physical and behavioral abnormalities which 
may cause an exaggerated reaction to pain); and a preliminary trial of intraspinal opioid drug administration 
must be undertaken with a temporary intrathecal/epidural catheter to substantiate adequately acceptable pain 
relief and degree of side effects (including effects on the activities of daily living) and patient acceptance. 
d.     Coverage of Other Uses of Implanted Infusion Pumps 
Determinations may be made on coverage of other uses of implanted infusion pumps if the MAC medical staff 
verifies that: 
 The drug is reasonable and necessary for the treatment of the individual patient; 
 It is medically necessary that the drug be administered by an implanted infusion pump; and, 
 The Food and Drug Administration-approved labeling for the pump must specify that the drug 
being administered and the purpose for which it is administered is an indicated use for the pump. 
e.     Implantation of Infusion Pump Is Contraindicated 
The implantation of an infusion pump is contraindicated in the following patients: 
With a known allergy or hypersensitivity to the drug being used (e.g., oral baclofen, morphine, etc.) ;or, 
Who have an active infection;or, 
Whose body size is insufficient to support the weight and bulk of the device; or, 
With other implanted programmable devices since crosstalk between devices may inadvertently change the 
prescription. 
NOTE: Payment may also be made for drugs necessary for the effective use of an implantable infusion pump 
as long as the drug being used with the pump is itself reasonable and necessary for the patient's treatment. 
You can find this rule at the Medicare National Coverage Determination (NCD) 280.14: Infusion Pumps. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.