Portable External Infusion Pump

Section: Durable Medical Equipment
Effective Date: April 01, 2020
Revised Date: May 19, 2020
Last Reviewed: May 19, 2020


Portable infusion pumps are small battery-driven devices which can be worn by the ambulatory patient (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.


A portable external infusion pump and related supplies may be considered medically necessary for the administration of drugs if the following set of 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 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 8 hours; or
  • The drug is administered by intermittent infusion (each episode of infusion lasting less than 8 hours) which does not require the member 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 as indicated in the Physicians Desk Reference, or the U.S. Pharmacopeia Drug Information.

Other usages of the portable infusion pump are covered if a medical review establishes the appropriateness of the therapy and of the prescribed pump for the individual patient.

Procedure Codes

A4222 A4230 A4231 A4232 A9274 E0779 E0780
E0781 E0784 E1399


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

  • 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 forTreatment 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 out-patient setting, including a hospice); or
  • Insulin for Diabetes Mellitus.
  • Other usages of the portable infusion pump are covered if a medical review establishes the appropriateness of the therapy and of the prescribed pump for the individual patient.

A portable external infusion pump not meeting the above criteria is considered not medically necessary.

Procedure Codes

A4222 A4230 A4231 A4232 A9274 E0779 E0780
E0781 E0784 E1399

Replacement Insulin Pump or replacement Personal Diabetes Manager (PDM) for Omnipod systems 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 or replacement PDM for Omnipod systems would be considered not medically necessary for a functioning insulin pump with an insulin pump with wireless communication to a glucose monitor or with a functioning PDM for Omnipod systems.

Omnipod® and Omnipod Dash™, programmable disposable external insulin delivery system may be considered medically necessary in children and adults with type 1 or type 2 diabetes.

Members who received the Omnipod Auero’s PDM and supplies between the dates April 1, 2019 and March 31, 2020 and were unable to obtain the DASH Omnipod system through the pharmacy in that timeframe may be eligible for benefits.

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

Procedure Codes

A4224 A4225 A4230 A4231 A4232 A9274 E0784

An ambulatory electrical infusion pump, may be considered medically necessary when used for the administration of epoprostenol. Payment may be made for only one pump for administering epoprostenol and treprostinil. 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 will be denied as not medically necessary.

Procedure Codes


All cannulas, needles, dressings and infusion supplies (excluding the insulin reservoir) related to continuous subcutaneous insulin infusion via external insulin infusion pump and the infusion sets and dressings related to subcutaneous immune globulin administration are limited to 1 unit of service per week, additional units will be denied as not medically necessary.

All supplies (including dressings) used in conjunction with a durable infusion pump are billed with (1) codes A4221 and A4222 or (2) codes A4221 and K0552. Other codes should not be used for the separate billing of these supplies. Codes A4230 (infusion set for external insulin pump, non-needle cannula type) and A4231 (infusion set for external insulin pump, needle type) are included in code A4221.

Replacement batteries are not separately payable when billed with a rented infusion pump.

Procedure Codes

A4221 A4230 A4231 E0779 E0780 E0781 E0784
E0791 K0455 K0552 K0601 K0602 K0603 K0604


The pump refilling and maintenance and cost of the drug are payable in accordance with coverage outlined in the member's benefits. Payment for chemotherapy administration may not be made in addition to pump refilling and maintenance since the portable infusion pump is easily filled and maintained. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Procedure Codes

96416 96425 96521


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 because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes


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 E11.21
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 E13.36 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 O24.415

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Added replacement criteria, added information about the Omnipod systems, added V-Go disposable insulin delivery device as experimental/investigational

Internal Medical Policy Committee 5-19-2020 Added statement "Members who received the Omnipod Auero’s PDM and supplies between the dates April 1, 2019 and March 31, 2020 and were unable to obtain the DASH Omnipod system through the pharmacy in that timeframe may be eligible for benefits."



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.