AGENCY FOR HEALTH CARE ADMINISTRATION
MedicaidRule No.: RULE TITLE
59G-4.230: Physician ServicesNOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 36 No. 18, May 7, 2010 issue of the Florida Administrative Weekly.
The amendment to Rule 59G-4.230, F.A.C., incorporates by reference the Florida Medicaid Physician Services Coverage and Limitations Handbook, January 2010.
The following section will replace the section titled “Intrathecal Baclofen Therapy” in the handbook as noticed in the proposed rule and will be inserted into the handbook in Chapter 2 between sections titled “Injectable Medication Services” and “Neonatal Critical Care Services.”
INTRATHECAL BACLOFEN THERAPY
Procedure Description
Intrathecal baclofen therapy (ITB) is used to manage severe spasticity of spinal cord or cerebral origin. The drug baclofen is infused through a surgically placed neuraxial catheter to a subcutaneously implanted infusion pump designed specifically for the administration of baclofen into the intrathecal space for continued therapy.
Indications for ITB Eligibility
The following criteria must be met before placing a recipient on ITB therapy:
●As indicated by at least a 6-week trial, the recipient cannot be maintained on non-invasive methods of spasm control, such as oral anti-spasmodic drugs (baclofen). These methods fail to control the spasticity adequately or produce intolerable side effects.
●Prior to implantation of the pump, the recipient has to respond favorably to a trial intrathecal dose of the anti-spasmodic drug baclofen.
●The recipient must have a positive response to a test bolus (by barbotage over not less than one (1) minute) of intrathecal baclofen by spinal catheter or lumbar puncture before initiating long term therapy.
●The intrathecal baclofen must be administered via an implantable pump that has been approved by the Food and Drug Administration specifically for the administration of baclofen into the intrathecal space for continued therapy.
HCPCS Codes Covered by Medicaid for ITB Therapy
Medicaid covers ITB therapy for qualifying candidates when the implantation service is rendered in the outpatient hospital setting only. The HCPCS codes below are designated to cover the ITB device. The hospital provider will use one or the other of these codes to bill Medicaid for the device, on the condition that prior authorization has been obtained and the hospital has a valid prior authorization number:
●E0783 Infusion pump system, implantable, programmable (includes all components, e.g., catheter, connectors, etc.)
●E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)
Important Note: E0786 (replacement pump) will be allowed no sooner than every 5 years.
Prior Authorization Required for ITB
Prior authorization from Medicaid is required before payment of the ITB device can be made to the outpatient hospital provider. The process for obtaining prior authorization is as follows:
1.The physician recommending the ITB treatment for a qualifying candidate requests prior authorization from the Medicaid office.
a.Prior authorization is requested using the PA 01 Form, Florida Medicaid Authorization Request. For instructions on how to complete the form, see Chapter 2 of the Medicaid Provider Reimbursement Handbook, CMS-1500.
b.On the PA 01 Form, the physician requests prior authorization for either E0783 or E0786, whichever one is applicable.
c.Documentation explaining what qualifies the candidate for the implantation of an ITB device for long term ITB therapy must be attached.
Note: The physician’s procedure to insert the device is already covered by Medicaid and requires no prior authorization. Only the device requires prior authorization and must be requested by the physician, not the hospital.
2.If Medicaid approves the ITB device, Medicaid will issue a prior authorization (PA) number. It is important that the physician gives this PA number to the hospital so the hospital can be reimbursed for the device. The physician billing for the insertion of the ITB pump needs no PA number on his CMS-1500 claim to Medicaid. Payment will be made to the physician for the insertion of the pump and not for the pump itself.
