Description

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.

Criteria

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

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

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

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

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

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

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."

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.