Clinical UM Guideline
|Subject:||External Infusion Pump|
|Guideline #:||CG-DME-21||Current Effective Date:||01/14/2014|
|Status:||Reviewed||Last Review Date:||11/14/2013|
This document addresses the use of external infusion pumps in the home or other residential care setting for diagnoses other than diabetes or pulmonary hypertension.
Note: Please see the following documents for further information regarding other types or uses for infusion pumps:
An external infusion pump is considered medically necessary for the administration of intravenous medications if either of the following sets of criteria (Criteria set 1 OR Criteria set 2) are met:
Criteria set 1
Criteria set 2
Not Medically Necessary:
External infusion pumps and related supplies are considered not medically necessary when the criteria described above are not met.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|E0779||Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater|
|E0780||Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours|
|E0781||Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient|
|E0791||Parenteral infusion pump, stationary, single or multi-channel|
|A4221||Supplies for maintenance of drug infusion catheter, per week (list drug separately)|
|A4222||Supplies for external drug infusion pump, per cassette or bag (list drug separately)|
|K0552||Supplies for external drug infusion pump, syringe type cartridge, sterile, each|
|K0601||Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each|
|K0602||Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each|
|K0603||Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each|
|K0604||Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each|
|K0605||Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2014]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2014]|
An ambulatory infusion pump is an electrical or battery operated device that is used to deliver solutions containing a parenteral drug under pressure at a regulated flow rate. It is small, portable, and designed to be carried by the individual being treated.
A stationary infusion pump is an electrical device that serves the same purpose as an ambulatory pump but is larger and typically mounted on a pole.
A reusable mechanical infusion pump is a device used to deliver solutions containing parenteral drugs under pressure at a constant flow rate determined by the tubing with which it is used. It is small, portable, and designed to be carried by the individual being treated. It must be capable of a single infusion cycle of at least 8 hours.
This Clinical UM Guideline is based on the Centers for Medicare and Medicaid Services (CMS) criteria.
Government Agency, Medical Society, and Other Authoritative Publications:
External Infusion Pumps
|Reviewed||11/14/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. No change to position statement.|
|Reviewed||11/08/2012||MPTAC review. No change to position statement. Updated Reference section.|
|Reviewed||11/17/2011||MPTAC review. No change to position statement. Updated Reference section.|
|Reviewed||11/17/2010||MPTAC review. No change to position statement. Updated Reference section.|
|Reviewed||11/19/2009||MPTAC review. No change to position statement. Updated Reference section.|
|Reviewed||11/20/2008||MPTAC review. No change to position statement.|
|Reviewed||11/29/2007||MPTAC review. References updated. Minor formatting changes.|
|Reviewed||12/07/2006||MPTAC review. References updated.|
|New||12/01/2005||MPTAC initial guideline development.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|Anthem, Inc.||No document|
|Anthem CO/NV||10/29/2004||DME.217||External Infusion Pumps|