This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

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.

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 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 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.

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.

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.

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.

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

The use of a portable external infusion pump is typically utilized on an outpatient basis which is only eligible for coverage on an inpatient basis in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

• Link to Provider Resource Center for the Medical Policy Update

12/2011, Additional coverage guidelines to be applied to external infusion pumps and supplies
04/2013, Place of service designation included on additional medical policies
03/2017, Coverage criteria updated for portable external infusion pumps

• Link to Diagnosis Codes

• Link to References