NASS Releases Coverage Policy Recommendations on Intrathecal Drug Delivery Systems

NASS Coverage Committee Co-Chair D. Scott Kreiner, MD spoke with SpineUniverse

Peer Reviewed

The North American Spine Society (NASS) released coverage policy recommendations on spinal intrathecal drug delivery systems (IDSS) for the treatment of nonmalignant pain (Table 1) and spasticity (Table 2) to help payers and spine professionals achieve a consensus on coverage.

To better understand these recommendations, SpineUniverse spoke with NASS Coverage Committee Co-Chair D. Scott Kreiner, MD, who is a specialist in physical medicine and rehabilitation at Ahwatukee Sports & Spine in Phoenix Arizona.
The word "review" under a magnifying glassSpineUniverse spoke with NASS Coverage Committee Co-Chair D. Scott Kreiner, MD, who is a specialist in physical medicine and rehabilitation.Q:  What are the potential benefits of intrathecal delivery of medications to treat pain and spasticity, and in which conditions may intrathecal delivery be of greatest advantage?

Dr. Kreiner: NASS recognizes the potential for abuse of narcotic medications and in general does not recommend the use of narcotics to treat chronic spine-related pain. However, there is a small subgroup of patients with chronic pain who may benefit from an intrathecal narcotic delivery system. In general, these are patients who have clear spinal pathology, but there is no other option to treat their symptoms. In addition, these patients should have a psychological evaluation to rule out drug and alcohol disorders and other psychological conditions. In the case of spasticity, slightly broader recommendations exist, though the prevalence of spasticity requiring this type of treatment is fairly uncommon. Patients with functionally-limiting spasticity that fails to respond to oral baclofen or who develop intolerable side effects of this medication may benefit from an intrathecal delivery system.

Q:  How can this coverage policy help physicians and their patients?

Dr. Kreiner: The idea behind not just this policy, but all of our coverage policies is to help inform both clinicians and payers on when the evidence supports using such a procedure. The policies not only serve as a resource to help providers and patients appeal non-coverage decisions by insurers, but they also provide appropriate restrictions and requirements to make sure that the patients are receiving the best possible care.

Q: What impact do you think this policy recommendation will have on the spine community and payer coverage policies?

Dr. Kreiner: We have seen many payers use NASS policies either to supplement their own internal coverage policies, or directly adapt them for coverage of spine-related procedures. We have been successfully working with various payers to ensure that patients have access to care when appropriate. We hope that this policy will be accepted by insurers to provide access of IDDS when appropriate.

Q:  Is there anything else you would like to emphasize to our readers?

Dr. Kreiner: NASS and its volunteer physicians spend many hours working on these coverage policies to assist payors, providers, and patients in defining appropriate and fair coverage decisions.

Table 1. NASS Coverage Recommendations for Nonmalignant Pain
Coverage is indicated when the following conditions are met:

  1. Severe chronic pain caused by verifiable spinal pathology with clinical manifestations known to be associated with the underlying condition.
  2. Patient has failed or could not tolerate other treatment methods, including but not limited to nonopioid medications, physical therapy and appropriate interventional (nonsurgical) treatments.
  3. Patient has demonstrated compliance with previous attempts to treat their condition.
  4. Demonstrable improvement of pain and function with systemic opiates and development of intolerable side effects, tolerance or hyperalgesia.
  5. Psychosocial evaluation to rule out active drug and alcohol disorders and psychiatric conditions
  6. Patient is not a candidate for other surgical interventions.
  7. Patient agrees to a 50% reduction in systemic opiates prior to undergoing an IT opiate trial. While undergoing the IT trial there is ≥50% decrease in pain with a concomitant increase in function.
  8. Patients who have had a successful trial agree to continue to taper their systemic opioids.
  9. Candidates have undergone a trial of IT treatment with at least 50% improvement in symptoms.

IDDS is contraindicated in patients with an active infection, active coagulopathy or when the patient’s body size is insufficient to support the weight and bulk of the evidence.

Table 2. NASS Coverage Recommendations for Spasticity
Coverage is indicated when the following conditions are met:

  1. Individuals with severe spasticity who either fail to respond to oral baclofen or develop intolerable side effects to the medication
  2. Patient has a baseline average Ashworth score of at least 3 and a Spasm Frequency score of at least 2 and demonstrates at least a 2-point reduction in the Ashworth or Spasm Frequency score for 4 hours following an intrathecal trial bolus of baclofen

IDDS is contraindicated in patients with an active infection, active coagulopathy or when the patient’s body size is insufficient to support the weight and bulk of the evidence.

Updated on: 03/20/18
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Scott Kreiner, MD
Physiatrist
Ahwatukee Sports and Spine
Phoenix, AZ
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