Portable External Infusion Pump (Medicaid Expansion)

Policy ID: ME-I-9017-004-04

Section: Durable Medical Equipment

Effective Date: December 01, 2022

Revised Date: April 24, 2024

Revision Effective Date: May 01, 2024

Last Reviewed: May 14, 2024

Applies To: Medicaid Expansion Only

Description

Portable infusion pumps are small battery-driven devices which can be worn by the ambulatory individual (usually attached to a belt). These pumps are attached to a needle or a catheter and are designed to provide continuous and/or intermittent delivery of a given drug. The most common usages include the infusion of insulin, chemotherapeutic agents, antibiotics, or heparin.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

A portable external infusion pump and related supplies may be considered medically necessary for the administration of drugs when ALL of the following criteria are met:

Parenteral administration of the drug in the home is reasonable and necessary; and
An infusion pump is necessary to safely administer the drug; and
The drug is administered by a prolonged infusion of at least eight (8) hours because of proven improved clinical efficacy; and
The therapeutic regimen is proven or generally accepted to have significant advantages over intermittent bolus administration regimens or infusions lasting less than eight (8) hours; and
The drug is administered by intermittent infusion (each episode of infusion lasting less than eight (8) hours) which does not require the individual to return to the physician's office prior to the beginning of each infusion; and
Systemic toxicity or adverse effects of the drug are unavoidable without infusing it at a strictly controlled rate.

A portable external infusion pump not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

A4222

E0779

E0780

E0781

E0784

E0787

E1399

Portable external infusion pumps and related supplies may be considered medically necessary for ANY ONE of the following criteria:

Iron poisoning - When used in the administration of deferoxamine for the treatment of acute iron poisoning and iron overload; or
Thromboembolic disease - When used in the administration of heparin for the treatment of thromboembolic disease and/or pulmonary embolism (covered only in an institutional setting); or
Chemotherapy for treatment of cancer; or
Morphine and other parenteral analgesics for treatment of severe, chronic cancer pain that is resistant to conventional therapy (in either an inpatient or outpatient setting, including a hospice); or
Insulin for Diabetes Mellitus.

A portable external infusion pump not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

A4222

E0779

E0780

E0781

E0784

E0787

E1399

Replacement Insulin Pump may be considered medically necessary for following indications:

Insulin infusion pumps that are out of warranty, are malfunctioning and cannot be repaired.
Replacement of an external insulin pump may be medically necessary for individuals who require the closed loop insulin pump system.

Replacement Pump would be considered not medically necessary for a functioning insulin pump with an insulin pump with wireless communication to a glucose monitor.

Replacing or upgrading an insulin pump due to individual convenience or newer technology when the current insulin pump remains functional would be considered not medically necessary.

Procedure Codes

E0784

E0787

A portable external infusion pump may be considered medically necessary when ALL of the following are met:

It is used for the administration of medications; and
Payment may be made for only one pump for administering the medications; and
The supplier is responsible for ensuring that there is an appropriate and acceptable contingency plan to address any emergency situations or mechanical failures of the equipment.

A second pump provided as a backup is considered a convenience item and is therefore, not a covered benefit.

A portable external infusion pump not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

K0455

All cannulas, needles, dressings and the infusion sets and dressings related to subcutaneous immune globulin administration are limited to one (1) unit of service per week. Additional units will be denied as not medically necessary.

Procedure Codes

A4221

K0552

The pump refilling and maintenance and cost of the drug are payable in accordance with coverage outlined in the member's benefits.

Procedure Codes

96416

96425

96521

Omnipod Insulin Management Systems

Omnipod insulin management systems may be covered through the pharmacy benefit.

Procedure Code

A9274

V-Go Disposable Insulin Delivery Device

V-Go disposable nonprogrammable insulin delivery device for the management of Type 1 or Type 2 diabetes mellitus is considered experimental/investigative and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

E1399

NOTE: Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.

Diagnosis Codes

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3521

E08.3522

E08.3523

E08.3529

E08.3531

E08.3532

E08.3533

E08.3539

E08.3541

E08.3542

E08.3543

E08.3549

E08.3551

E08.3552

E08.3553

E08.3559

E08.3591

E08.3592

E08.3593

E08.3599

E08.36

E08.37X1

E08.37X2

E08.37X3

E08.37X9

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E08.65

E08.69

E08.8

E08.9

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3521

E09.3522

E09.3523

E09.3529

E09.3531

E09.3532

E09.3533

E09.3539

E09.3541

E09.3542

E09.3543

E09.3549

E09.3551

E09.3552

E09.3553

E09.3559

E09.3591

E09.3592

E09.3593

E09.3599

E09.36

E09.37X1

E09.37X2

E09.37X3

E09.37X9

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E09.65

E09.69

E09.8

E09.9

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3539

E10.3541

E10.3542

E10.3543

E10.3549

E10.3551

E10.3552

E10.3553

E10.3559

E10.3591

E10.3592

E10.3593

E10.3599

E10.36

E10.37X1

E10.37X2

E10.37X3

E10.37X9

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.10

E11.11

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3521

E11.3522

E11.3523

E11.3529

E11.3531

E11.3532

E11.3533

E11.3539

E11.3541

E11.3542

E11.3543

E11.3549

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.37X9

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3521

E13.3522

E13.3523

E13.3529

E13.3531

E13.3532

E13.3533

E13.3539

E13.3541

E13.3542

E13.3543

E13.3549

E13.3551

E13.3552

E13.3553

E13.3559

E13.3591

E13.3592

E13.3593

E13.3599

E13.37X1

E13.37X2

E13.37X3

E13.37X9

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

E13.65

E13.69

E13.8

E13.9

O24.011

O24.012

O24.013

O24.019

O24.02

O24.03

O24.111

O24.112

O24.113

O24.119

O24.12

O24.13

O24.311

O24.312

O24.313

O24.319

O24.32

O24.33

O24.410

O24.414

O24.419

O24.420

O24.424

O24.429

O24.430

O24.434

O24.439

O24.811

O24.812

O24.813

O24.819

O24.82

O24.83

O24.911

O24.912

O24.913

O24.919

O24.92

O24.93

O99.810

O99.814

O99.815

P70.2

Z79.4

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 Adopted Medicaid Expansion specific policy effective 1-1-2022

Internal Medical Policy Committee 11-29-2022 - Effective December 01, 2022

Updated Omnipod statement to read 'Omnipod insulin management systems may be a covered pharmacy benefit.'

Internal Medical Policy Committee 1-26-2023 - Effective December 01, 2022

Reverted updated Omnipod statement back to 'Omnipod insulin management systems are not a covered benefit.'

Internal Medical Policy Committee 1-16-2024 Effective March 01, 2024

Annual review no clinical content change

Internal Medical Policy Committee 5-14-2024 Effective May 01, 2024

Updated Omnipod criteria to 'Omnipod insulin management systems may be covered through the pharmacy benefit.' based on updates in the DHHS PDL Version 2024.3

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: ME-I-9017-004-03

Section: Durable Medical Equipment

Effective Date: December 01, 2022

Revised Date: January 15, 2024

Revision Effective Date: March 01, 2024

Last Reviewed: January 16, 2024

Archived Date: April 30, 2024

Applies To: Medicaid Expansion Only

Description

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

A portable external infusion pump and related supplies may be considered medically necessary for the administration of drugs when ALL of the following criteria are met:

Parenteral administration of the drug in the home is reasonable and necessary; and
An infusion pump is necessary to safely administer the drug; and
The drug is administered by a prolonged infusion of at least eight (8) hours because of proven improved clinical efficacy; and
The therapeutic regimen is proven or generally accepted to have significant advantages over intermittent bolus administration regimens or infusions lasting less than eight (8) hours; and
The drug is administered by intermittent infusion (each episode of infusion lasting less than eight (8) hours) which does not require the individual to return to the physician's office prior to the beginning of each infusion; and
Systemic toxicity or adverse effects of the drug are unavoidable without infusing it at a strictly controlled rate.

A portable external infusion pump not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

A4222

E0779

E0780

E0781

E0784

E0787

E1399

Portable external infusion pumps and related supplies may be considered medically necessary for ANY ONE of the following criteria:

Iron poisoning - When used in the administration of deferoxamine for the treatment of acute iron poisoning and iron overload; or
Thromboembolic disease - When used in the administration of heparin for the treatment of thromboembolic disease and/or pulmonary embolism (covered only in an institutional setting); or
Chemotherapy for treatment of cancer; or
Morphine and other parenteral analgesics for treatment of severe, chronic cancer pain that is resistant to conventional therapy (in either an inpatient or outpatient setting, including a hospice); or
Insulin for Diabetes Mellitus.

A portable external infusion pump not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

A4222

E0779

E0780

E0781

E0784

E0787

E1399

Replacement Insulin Pump may be considered medically necessary for following indications:

Insulin infusion pumps that are out of warranty, are malfunctioning and cannot be repaired.
Replacement of an external insulin pump may be medically necessary for individuals who require the closed loop insulin pump system.

Replacement Pump would be considered not medically necessary for a functioning insulin pump with an insulin pump with wireless communication to a glucose monitor.

Replacing or upgrading an insulin pump due to individual convenience or newer technology when the current insulin pump remains functional would be considered not medically necessary.

Procedure Codes

E0784

E0787

A portable external infusion pump may be considered medically necessary when ALL of the following are met:

It is used for the administration of medications; and
Payment may be made for only one pump for administering the medications; and
The supplier is responsible for ensuring that there is an appropriate and acceptable contingency plan to address any emergency situations or mechanical failures of the equipment.

A second pump provided as a backup is considered a convenience item and is therefore, not a covered benefit.

A portable external infusion pump not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

K0455

Procedure Codes

A4221

K0552

The pump refilling and maintenance and cost of the drug are payable in accordance with coverage outlined in the member's benefits.

Procedure Codes

96416

96425

96521

Omnipod Insulin Management Systems

Omnipod insulin management systems are not a covered benefit.

Procedure Code

A9274

V-Go Disposable Insulin Delivery Device

Procedure Code

E1399

NOTE: Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.

Diagnosis Codes

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3521

E08.3522

E08.3523

E08.3529

E08.3531

E08.3532

E08.3533

E08.3539

E08.3541

E08.3542

E08.3543

E08.3549

E08.3551

E08.3552

E08.3553

E08.3559

E08.3591

E08.3592

E08.3593

E08.3599

E08.36

E08.37X1

E08.37X2

E08.37X3

E08.37X9

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E08.65

E08.69

E08.8

E08.9

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3521

E09.3522

E09.3523

E09.3529

E09.3531

E09.3532

E09.3533

E09.3539

E09.3541

E09.3542

E09.3543

E09.3549

E09.3551

E09.3552

E09.3553

E09.3559

E09.3591

E09.3592

E09.3593

E09.3599

E09.36

E09.37X1

E09.37X2

E09.37X3

E09.37X9

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E09.65

E09.69

E09.8

E09.9

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3539

E10.3541

E10.3542

E10.3543

E10.3549

E10.3551

E10.3552

E10.3553

E10.3559

E10.3591

E10.3592

E10.3593

E10.3599

E10.36

E10.37X1

E10.37X2

E10.37X3

E10.37X9

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.10

E11.11

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3521

E11.3522

E11.3523

E11.3529

E11.3531

E11.3532

E11.3533

E11.3539

E11.3541

E11.3542

E11.3543

E11.3549

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.37X9

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3521

E13.3522

E13.3523

E13.3529

E13.3531

E13.3532

E13.3533

E13.3539

E13.3541

E13.3542

E13.3543

E13.3549

E13.3551

E13.3552

E13.3553

E13.3559

E13.3591

E13.3592

E13.3593

E13.3599

E13.37X1

E13.37X2

E13.37X3

E13.37X9

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

E13.65

E13.69

E13.8

E13.9

O24.011

O24.012

O24.013

O24.019

O24.02

O24.03

O24.111

O24.112

O24.113

O24.119

O24.12

O24.13

O24.311

O24.312

O24.313

O24.319

O24.32

O24.33

O24.410

O24.414

O24.419

O24.420

O24.424

O24.429

O24.430

O24.434

O24.439

O24.811

O24.812

O24.813

O24.819

O24.82

O24.83

O24.911

O24.912

O24.913

O24.919

O24.92

O24.93

O99.810

O99.814

O99.815

P70.2

Z79.4

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 Adopted Medicaid Expansion specific policy effective 1-1-2022

Internal Medical Policy Committee 11-29-2022 - Effective December 01, 2022

Updated Omnipod statement to read 'Omnipod insulin management systems may be a covered pharmacy benefit.'

Internal Medical Policy Committee 1-26-2023 - Effective December 01, 2022

Reverted updated Omnipod statement back to 'Omnipod insulin management systems are not a covered benefit.'

Internal Medical Policy Committee 1-16-2024 Effective March 01, 2024

Annual review no clinical content change

Medical Policies Quick Search

Portable External Infusion Pump (Medicaid Expansion)

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Omnipod Insulin Management Systems

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Professional Statements and Societal Positions Guidelines

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Description

Criteria

Omnipod Insulin Management Systems

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer