Payment may be made for the portable infusion pump (A9274, E0779, E0780, E0781, E0784, E1399) and related supplies (A4222, A4230-A4232, K0552) for the following:

1. Iron Poisoning - When used in the administration of deferoxamine for the treatment of acute iron poisoning and iron overload.
2. 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).
3. Chemotherapy for Treatment of Cancer
4. 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).
5. Insulin for Diabetes Mellitus - See Medical Policy Bulletin E-15 for information on coverage for these devices (A9274, E0784).

Code K0455 describes an ambulatory electrical infusion pump, which is used for the administration of epoprostenol. Payment will be made for only one pump (K0455) 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. A participating, preferred or network provider cannot bill the member for the denied device.

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

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.

Code A4221 includes dressings for the catheter site and flush solutions not directly related to drug infusion. The catheter site may be a peripheral intravenous line, a peripherally inserted central catheter (PICC), a centrally inserted intravenous line with either an external or a subcutaneous port, or an epidural catheter. Code A4221 also includes all cannulas, needles, dressings and infusion supplies (excluding the insulin reservoir) related to continuous subcutaneous insulin infusion via external insulin infusion pump (E0784) and the infusion sets and dressings related to subcutaneous immune globulin administration. Billing for more than 1 unit of service per week is incorrect use of the code and will be denied as not medically necessary.

Code A4222 includes the cassette or bag, diluting solutions, tubing and other administration supplies, port cap changes, compounding charges, and preparation charges. This code is not used for a syringe-type reservoir.

All supplies (including dressings) used in conjunction with a durable infusion pump (E0779, E0780, E0781, E0784, E0791, K0455) 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.

The pump refilling and maintenance (96521) and cost of the drug are payable in accordance with coverage outlined in the member's benefits. Payment for chemotherapy administration (96416, 96425) may not be made in addition to code 96521 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.

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

Coverage for DME is determined according to individual or group customer benefits. 

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

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.

NOTE:

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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

DME MAC Jurisdiction A L5044