Implantable Pain Therapy

Policy

The TAC can pay the reasonable costs of clinically justified Implantable Pain Therapy when required as a result of a transport accident injury under section 60 of the Transport Accident Act 1986.

The TAC adopts the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for surgical services provided by medical practitioners. 

This policy must be read in conjunction with the following:

• Medical Practitioner policy 
• Surgery (Elective) policy 
• Hospitals - Private policy
• Surgically Implanted Prostheses policy 
• Medicare Benefits Schedule (MBS).

DEFINITIONS

In this policy, Implantable Pain Therapy (IPT) is a procedure involving the use of an implantable device to address persistent pain and may be considered when a range of alternatives for managing persistent pain have been fully explored. Many IPT procedures remain non-established or experimental.

There are three stages to IPT:

Stage 1: A trial of neurostimulation or a trial of intrathecal analgesia
Stage 2: Implantation of a permanent IPT device
Stage 3: IPT required for a technical purpose such as battery or device replacement

IPT incorporates:

• intrathecal morphine infusion and other analgesic infusions (also known as intraspinal pumps)
• neurostimulation techniques such as:
• • spinal cord stimulation
  • subcutaneous electrical stimulation
  • peripheral nerve stimulation
  • deep brain stimulation
  • motor cortex stimulation
  • other implanted neurostimulation devices for pain.

GUIDELINES

What can the TAC pay for in relation to IPT?

The TAC can pay the reasonable costs of an IPT procedure where:

• the persistent pain condition has resulted from a transport accident injury
• alternative options for managing persistent pain have been fully explored and have not been successful
• it is safe, effective and clinically justified, based on the client's physical, psychological and functional status 
• the procedure has an item number in the MBS
• the anticipated implantable prosthesis is listed on and provided in accordance with the Surgically Implanted Prostheses policy
• it is required for a technical purpose, such as a battery/device replacement, reprogramming or a refill (where the initial IPT was paid for by the TAC).

The TAC can pay the reasonable costs of:

• a trial of neurostimulation of a minimum of one week duration and a maximum of two week duration in an outpatient setting and approved by the TAC or intrathecal analgesia trial approved by the TAC
• IPT approved by the TAC following an approved, successful trial of neurostimulation or intrathecal analgesia
• only one IPT for a client unless a subsequent procedure is required for technical purposes and that procedure is approved by the TAC
• battery/device replacement approved by the TAC following approved IPT
• hospital services associated with IPT procedures
• prostheses in accordance with the Surgically Implanted Prostheses policy.

When replacement or modification of a prosthesis used for IPT is required, and the prosthesis is covered by a supplier/manufacturer warranty, it is the responsibility of the manufacturer to replace or modify the prosthesis or its components.

Who can provide IPT?

IPT is to be requested and performed by a registered medical practitioner with expertise in the area of IPT.

What information does the TAC require to consider paying for IPT?

To consider paying for IPT, the TAC requires information from the treating medical practitioner and information obtained by the TAC from other health providers.

INFORMATION REQUIRED FROM THE TREATING MEDICAL PRACTITIONER

To expedite payment of accounts, the TAC encourages prior approval be sought by the treating medical practitioner.

The TAC requires a written request for IPT from the treating medical practitioner. IPT is to be requested and approved in stages and different information is required depending on the stage of treatment that is being requested. 

The following sections outline in detail the information required from the treating medical practitioner to request IPT, depending on the stage of the treatment.  The information required is necessary for the TAC to make an informed decision. Please note that if an IPT request does not include all the information required, the TAC will not review the request.

Stage 1: A trial of neurostimulation or a trial of intrathecal analgesia

The request for a trial of either neurostimulation or intrathecal analgesia should include an assessment and written clinical rationale from the treating medical practitioner, including:

1. The condition(s) being treated.
2. The relationship between the condition(s) being treated and the transport accident injury.
3. A brief description of the IPT procedure with details of the prosthetic items to be used, in accordance with the Surgically Implanted Prostheses policy.
4. The clinical indication for the IPT procedure, including reasons why more conservative treatments that the client has tried for pain management have not been effective. 
5. A list of all current medications taken by the client, including any medication dependency issues.
   • participation in activities of daily living and work
   • mobility
   • pain levels and mood
   • medication use (i.e. expected reductions).
6. Anticipated effects the IPT procedure will have on the client's:
7. Objective pre- and post-IPT outcome measures that will be used to measure the effectiveness of the procedure.
   • the medications expected to be required
   • who will be responsible for the client's short and long term care
   • who will be responsible for changing batteries, refills and reprogramming (where required) 
   • other therapists to be involved to maximise functional gains following IPT, e.g. physiotherapist, occupational therapist, return to work specialist, etc.
   • other treatments being considered if the procedure is not successful.
8. Anticipated treatment plan following IPT procedure, including:

Stage 2: Implantation of a permanent IPT device, following an approved trial

If the outcome of an approved trial of neurostimulation or intrathecal analgesia supports the implantation of a permanent IPT device, the TAC requires a request for a permanent IPT device from the requesting medical practitioner which includes:

1. The objectively measured outcomes of the trial in order to assess a request for a permanent IPT.
2. A brief description of the IPT procedure with details of the prosthetic items to be used, in accordance with the Surgically Implanted Prostheses policy.

Stage 3: IPT required for a technical purpose such as battery or device replacement

The request from the requesting medical practitioner must include:

1. Justification stating why the procedure or replacement is required.
2. Evidence of the effectiveness of the IPT to date, including effect on the pain and function of the client.
3. A brief description of the IPT procedure with details of the prosthetic items to be used, in accordance with the Surgically Implanted Prostheses policy.
4. An indication of whether the replacement device parts are under warranty and if not, when the warranty on the parts expired.
5. An indication of the urgency of the request.

INFORMATION THE TAC MAY OBTAIN FROM OTHER HEALTH PROVIDERS

In addition to the information provided by the treating medical practitioner in the request for IPT, the TAC may arrange for the client to be assessed by an independent medical examiner with expertise in IPT.

The TAC will also review information regarding a client's psychological suitability to undergo IPT.  This information may be from:

• an independent medical examination with a psychiatrist, arranged by the TAC; and/or
• the client's treating psychologist or treating psychiatrist, but only at the request of the TAC.

When will the TAC respond to a request?

The TAC will respond to written treatment and service requests as per the TAC Service Charter.

What fees are payable for IPT?

The TAC can pay the reasonable costs of IPT in accordance with the:

• Reimbursement Rates for Medical Services 
• Surgically Implanted Prostheses policy 
• Hospitals - Private policy.

In relation to IPT, what will the TAC not pay for?

The TAC will not pay for:

• treatment or services that are contra-indicated on physical, psychological or functional grounds
• treatment or services that form part of a clinical trial
• reports not requested by the TAC
• services that are not in accordance with the MBS guidelines - refer to the Non-Established, New or Emerging Treatment and Services (NeNETS) policy 
• IPT where alternative options for managing persistent pain have not been fully explored
• modification or replacement of an IPT device that is covered by supplier/manufacturer warranty
• treatment or services for a person other than the client
• fees associated with cancellation or non attendance
• treatment or services provided outside the of Australia
• treatment or services provided by telephone or other non face to face mediums 
• the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
• treatment or services received more than 2 years prior to the request for funding except where the request for payment is made within 3 years of the transport accident - Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.