Pain Management Medicare Guidelines

To qualify for narcotic analgesic, benefit to the patient must be diagnosed with intractable pain caused by cancer that has not responded to an adequate oral/transdermal therapeutic regimen and/or cannot tolerate oral/transdermal narcotic analgesics.

Documentation in progress notes outlining pain history and response to other analgesics required.

Chartwell reviews all eligible Medicare patients for infusion qualification based on the Noridian LCD found at: External Infusion Pumps. Noridian has the most current and up to date information. Please refer to the Noridian site for clarification of any content on this site.

Some therapies will have fill and total dose limitations with each qualifying diagnosis. Some therapies will require an electronic external infusion pump, while others will prohibit use of an electronic pump based on the LCD. Medicare covers home infusion under their external infusion pump coverage within the Durable Medical Equipment benefit.

For qualification, provider documentation requires diagnostic testing to support diagnosis for all therapies requiring Medicare qualification. Additionally:
  • The patient must be eligible for a defined Medicare benefit category.
  • Therapy must be reasonable and necessary for the diagnosis and supported in medical documentation.
  • The case must meet all other applicable Medicare statutory and regulatory requirements.