Blue Cross of Idaho Logo

Express Sign-on

Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member under age 65, please register here.

If you are an Medicare or Medicare Supplement member, please register here.

New Options for Affordable Health Insurance

MP 1.01.08

(Archived) External Infusion Pumps


Medical Policy
Section
Durable Medical Equipment
 
Original Policy Date
3/9/96

Last Review Status/Date
Archived/2:2011

Issue
1:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

An external infusion pump (EIP) is a portable device intended to provide continuous ambulatory drug infusion therapy over an extended time period. The EIP is also known as an external pump, ambulatory pump, or a mini-infuser. The EIP is usually the size of a portable cassette player and can be worn on a belt around the patient’s waist or from a shoulder harness. It is a battery driven device.

Proposed drug delivery routes using the EIP include the intravenous, intra-arterial, sub-cutaneous, intraperitoneal, epidural, intrathecal, and intraventricular routes. A heparinized saline solution may be used during an interruption of drug therapy to maintain catheter patency. The EIP is battery powered, and drug reservoir refilling is non-invasive. A catheter from the pump is attached to the desired access route for drug delivery.


Policy

Use of the EIP for the administration of the following drugs is considered medically necessary for selected patients on:

  • morphine and other parenteral analgesics for treatment of severe, chronic cancer pain that is resistant to conventional therapy. Acceptable routes are subcutaneous (SC) and intravenous (IV);
  • insulin for treatment of insulin-dependent diabetes mellitus in patients who cannot be controlled by intermittent dosing. Acceptable routes are SC and IV;
  • heparin for treatment of severe thromboembolic disease that cannot be managed conventionally (e.g., complicated pregnancy). Acceptable routes are SC and IV;
  • chemotherapeutics for treatment of cancer. Acceptable routes are stipulated in the drug labeling and might include either IV or intra-arterial (IA).


Policy Guidelines

Patient selection is key to appropriate utilization of the EIP. Factors relevant to the selection of EIP candidates may include several of the following conditions:

  • Patient is ambulatory and treatment can be appropriately delivered on an outpatient basis, with an expected improvement in the quality of life;
  • Drug therapy is ongoing and a therapeutic advantage is expected by using continuous (or pulsatile) infusion rather than intermittent injections;
  • Patient is otherwise treatable only by conventional infusion pump in an institutional setting, or compliance difficulties make intermittent injection ineffective;
  • Patient education protocols are documented and emergency support is available when unexpected adverse events occur; and
  • Presence of favorable technical factors, such as a convenient, safe, and reliable EIP delivery system along with correct placement of the needle and catheter exist.


Benefit Application

BlueCard/National Account Issues

Portable external infusion pumps are adjudicated under Durable Medical Equipment. There are over 600 different models of pumps, most of which have been received clearance for marketing by the Food and Drug Administration (FDA) through a pre-notification application (510 (K)).


Rationale

A search of the literature was completed through the MEDLINE database for the period of January 1992 through May 1995. The search strategy focused on references containing the following Medical Subject Headings:

– Infusion Pumps
 
– Portable or External or Ambulatory

Research was limited to English-language journals on humans.

See also:

TEC Evaluations 1989: p. 59

 

Codes

Number

Description

CPT  No Code 
ICD-9 Procedure  No Code 
ICD-9 Diagnosis    Morphine
 
See pain for specific body part 
  250.3   Insulin
 
Insulin-dependent diabetes, uncontrolled 
  444.9  Heparin
 
Arterial embolism and thrombosis of unspecified artery 
    Chemotherapeutics
 
See cancer codes 
HCPCS  E0781  Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient 
Type of Service  DME 
Place of Service  Inpatient
 
Outpatient
 
Home
 


Index

Infusion Pumps, External
External Infusion Pumps
Pump, Portable Infusion


Policy History

Date Action Reason
03/09/96 Add to Mental Health section New Policy
04/15/02 Replace Policy Policy reviewed without literature review; new review date only
04/29/03 Replace Policy Policy no longer scheduled for routine literature review.
2/2011 Policy archived  

Search for Policies

Policy Feedback