Clinical UM Guideline


Subject:  External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings
Guideline #:  CG-DME-21Current Effective Date:  02/09/2015
Status:RevisedLast Review Date:  02/05/2015

Description

This document addresses the use of external infusion pumps for the administration of parenteral or enteral drugs in the home or other residential care settings for diagnoses other than diabetes mellitus or pulmonary hypertension. The administration of oral or enteral nutrition is not addressed in this document.

Note: Please see the following documents for further information regarding other types or uses for infusion pumps:

 Note: Please see the following document for information regarding the administration of oral or enteral nutrition:

Note: Please see the document below for additional information regarding the use of carbidopa and levodopa intestinal suspension.

Clinical Indications

Medically Necessary:

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

An external infusion pump is considered medically necessary for the administration of enteral medications when all of the following criteria have been met:

Not Medically Necessary: 

External infusion pumps and related supplies are considered not medically necessary when the criteria described above are not met.

An external infusion pump is considered not medically necessary for the administration of enteral medications when the criteria above have not been met.

Coding

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.

HCPCS 
 Equipment
E0776IV pole
E0779Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater
E0780Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours
E0781Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient
E0791Parenteral infusion pump, stationary, single or multi-channel
  
 Supplies
A4221Supplies for maintenance of drug infusion catheter, per week (list drug separately)
A4222Supplies for external drug infusion pump, per cassette or bag (list drug separately)
K0552Supplies for external drug infusion pump, syringe type cartridge, sterile, each
K0601Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each
K0602Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each
K0603Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each
K0604Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each
K0605Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

An ambulatory infusion pump is an electrical or battery operated device that is used to deliver solutions containing a 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 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.

Definitions

Enteral: Route of administration through the gastrointestinal tract.

Parenteral: Route of administration other than the gastrointestinal tract (e.g. intravenous, intramuscular, intraperitoneal).

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. National Coverage Determinations. Available at:  http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd.  Accessed on January 12, 2015.
    • Durable Medical Equipment Reference List.  NCD #280.1. Effective May 5, 2005.
    • Infusion Pumps. NCD #280.14. Effective December 17, 2004.
  2. Carbidopa and levodopa (Duopa) [Product Information], North Chicago, IL. AbbieVie Inc. January 2015. Available at: http://www.rxabbvie.com/pdf/duopa_pi.pdf.  Accessed on January 12, 2015.
Index

External Infusion Pumps

Document History
StatusDateAction
Revised02/05/2015Medical Policy & Technology Assessment Committee (MPTAC) review.  Revised Title and Description sections to clarify scope of document.  Added new medically necessary and not medically necessary statements for continuous administration of enteral drugs.  Added Definitions section. Updated Rationale and Reference sections.
Reviewed08/14/2014MPTAC review. 
Reviewed11/14/2013MPTAC review. 
Reviewed11/08/2012MPTAC review.  Updated Reference section.
Reviewed11/17/2011MPTAC review.  Updated Reference section.
Reviewed11/17/2010MPTAC review.  Updated Reference section.
Reviewed11/19/2009MPTAC review.  Updated Reference section.
Reviewed11/20/2008MPTAC review.  
Reviewed11/29/2007MPTAC review. References updated. Minor formatting changes.
Reviewed12/07/2006MPTAC review. References updated.
New12/01/2005MPTAC initial guideline development.
   
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem, Inc.  No document
Anthem CO/NV10/29/2004DME.217External Infusion Pumps