Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 11202 | Palmetto GBA | A and B and HHH MAC | SC |
| 11302 | Palmetto GBA | A and B and HHH MAC | VA |
| 11402 | Palmetto GBA | A and B and HHH MAC | WV |
| 11502 | Palmetto GBA | A and B and HHH MAC | NC |
| 10112 | Palmetto GBA | A and B MAC | AL |
| 10212 | Palmetto GBA | A and B MAC | GA |
| 10312 | Palmetto GBA | A and B MAC | TN |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56695 (Billing and Coding: Implantable Infusion Pump) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56695: Billing and Coding: Implantable Infusion Pump (Billing and Coding, effective 2026-10-01)
- Covered ICD-10-CM codes
- 2020
- 3 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 29
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| A18.01 | — |
| B02.23 | — |
| C00.0 | — |
| C00.1 | — |
| C00.3 | — |
| C00.4 | — |
| C00.6 | — |
| C00.8 | — |
| C01 | Malignant neoplasm of base of tongue |
| C02.0 | — |
| C02.1 | — |
| C02.2 | — |
| C02.3 | — |
| C02.4 | — |
| C02.8 | — |
| C02.9 | — |
| C03.0 | — |
| C03.1 | — |
| C04.0 | — |
| C04.1 | — |
| C04.8 | — |
| C04.9 | — |
| C05.0 | — |
| C05.1 | — |
Procedure codes: 36260, 36261, 36262, 62322, 62323, 62326, 62327, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990, 95991, 96522, A4220 (Refill Kit For Implantable Infusion Pump), E0782 (Infusion Pump, Implantable, Non-Programmable (Includes All Components, E.G., Pump, Catheter, Connectors, Etc.)), E0783 (Infusion Pump System, Implantable, Programmable (Includes All Components, E.G., Pump, Catheter, Connectors, Etc.)), E0785 (Implantable Intraspinal (Epidural/Intrathecal) Catheter Used With Implantable Infusion Pump, Replacement), E0786 (Implantable Programmable Infusion Pump, Replacement (Excludes Implantable Intraspinal Catheter)), J2274 (Injection, Morphine Sulfate, Preservative-Free For Epidural Or Intrathecal Use, 10 Mg), J2278 (Injection, Ziconotide, 1 Microgram), J7999 (Compounded Drug, Not Otherwise Classified), J9200 (Injection, Floxuridine, 500 Mg).
Coverage indications, limitations and medical necessity
The implantable pump is a sealed, self-powered system, which is inserted under the skin by a physician. It provides a continuous controlled infusion of a drug to a select body site and can be refilled by percutaneous injection. Two separate ports are available: 1 for bolus injections and 1 for continuous infusion. Both may be utilized for blood or cerebrospinal fluid (CSF) withdrawals. An implantable infusion pump is utilized to administer many types of medications through the intra-arterial, intrathecal or epidural route.
Medicare will consider implantable infusion pumps, and associated services, medically reasonable and necessary for the conditions listed in the CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §280.14 Infusion Pumps.
For the indication of opioid drugs used for the treatment of chronic intractable pain, it is useful to distinguish between pain caused by a malignancy from which the patient is not expected to recover from those non-malignant conditions that are longer term in nature. For terminal malignant conditions, the progression from a non-invasive pain control modality to a more invasive modality, such as use of an implanted pump, may occur more rapidly with less emphasis on behavioral approaches to pain control.
Ziconotide ( Prialt® ) intrathecal infusion documentation must meet the Food and Drug Administration (FDA)-approved indication that the patient is intolerant of or refractory to other treatment, such as systemic analgesics, adjunctive therapies or intrathecal therapy morphine in the treatment of severe, chronic pain.
Contraindication
The implantation of an infusion pump is contraindicated in the following patients:
• Those with a known allergy or hypersensitivity to the drug being used (e.g., oral baclofen and morphine)
• Those who have an infection
• Those whose body size is insufficient to support the weight and bulk of the device
In those patients with other implanted programmable devices, since crosstalk between devices may inadvertently change the prescription, it is recommended that all devices be checked for possible crosstalk at the time of implantation of the infusion pump, and that appropriate surveillance for such interactions be continued.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2024-03-07
- Last reviewed by the contractor
- 2024-01-31
- MCD version
- 64
- Derived from
- L31790
The contractor lists one National Coverage Determination as related: NCD 280.14 Infusion Pumps. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Palmetto GBA hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L33461 cover?
The implantable pump is a sealed, self-powered system, which is inserted under the skin by a physician. It provides a continuous controlled infusion of a drug to a select body site and can be refilled by percutaneous injection. Two separate ports are available: 1 for bolus injections and 1 for continuous infusion. Both may be utilized for blood or cerebrospinal fluid (CSF) withdrawals. An implantable infusion pump… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33461 apply to?
Palmetto GBA applies it to Medicare claims in AL, GA, NC, SC, TN, VA, WV. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33461?
The companion billing and coding article A56695 lists 2,020 ICD-10-CM codes in 3 groups that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L33461?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.