Mountain State Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-17
Topic: Portable External Infusion Pump
Effective Date: January 1, 2008
Issued Date: December 31, 2007
Date Last Reviewed: 12/2007

General Policy Guidelines

Indications and Limitations of Coverage

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 B-46 for information on coverage for these devices (A9274, E0784).
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. See Medical Policy Bulletin I-18 for information on continuous infusion of epoprostenol (Flolan), code K0455.

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.

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.

Procedure Codes

964169642596521A4222A4230A4231
A4232A9274E0779E0780E0781E0784
E1399K0455K0552   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

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.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

TriCenturion L5044

MPRM 1.01.08

View Previous Versions

[Version 003 of E-17]
[Version 002 of E-17]
[Version 001 of E-17]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

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