Highmark Commercial Medical Policy - Pennsylvania

Medical Policy: E-17-020
Topic: Portable External Infusion Pump
Section: Durable Medical Equipment
Effective Date: September 11, 2017
Issue Date: July 23, 2018
Last Reviewed: June 2018

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.

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.

Policy Position 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 if the following set of criteria are met:

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:


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

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, K0605

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

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

See Medical Policy Bulletin S-40 for information on the implantable infusion pump.

See Medical Policy Bulletin I-18 for information on epoprostenol (Flolan).

See Medical Policy Bulletin E-15 for information on coverage for these devices.

See Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Place of Service: Outpatient

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.

The policy position applies to all commercial lines of business

Denial Statements

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.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.