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MP 1.01.99

Insulin Infusion Pumps for the Treatment of Diabetes Mellitus


Medical Policy    
Section
Durable Medical Equipment
Original Policy Date
03/19/08

Last Review Status/3Date
Reviewed local policy/10:2013

Issue
10:2013
  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 insulin infusion pump is a battery-operated device worn about the waist and attached to a subcutaneous needle or catheter that provides continuous infusion of insulin. The purpose of the insulin pump is to provide an accurate, continuous controlled delivery of insulin which can be regulated by the user to achieve intensive glucose control objectives.  This document addresses the medically necessary uses of these devices.


Policy

External insulin infusion pumps are considered medically necessary for the treatment of diabetes mellitus for members when all of the following are met:

  • Completion of a comprehensive diabetes education program
  • A schedule of multiple daily injections of insulin (i.e., at least 3 injections per day), with frequent self-adjustments of insulin dose for at least 6 months prior to initiation of the insulin pump
  • Documented frequency of glucose self-testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump
  • The member meets at least one of the following criteria while on multiple daily injections (more than 3 injections per day) of insulin:
    • Elevated glycosylated hemoglobin level (A1c greater than 7.0%, where the upper range of normal is less than 6.%; for other A1c assays, 1% over upper range of normal); or
    • History of recurring hypoglycemia (less than 60 mg/dL); or
    • Wide fluctuations in blood glucose before mealtime (e.g., pre-prandial blood glucose levels commonly exceed 140 mg/dL); or
    • Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; or
    • History of severe glycemic excursions

An exception to the above medical necessity criteria may be made for a member with Type I diabetes during pregnancy, if initiation of an external insulin infusion pump is required to avoid fetal and maternal complications of 

diabetes and pregnancy.  If a woman is attempting to conceive, this may not be the best time to begin pump therapy. If a patient is already on the pump and doing well, pumps may be continued during pregnancy. However, because of the small risk for increased diabetic ketoacidosis episodes with pump therapy, starting the pump at these times results in possible increased risk for miscarriage.

External insulin infusion pumps are considered not medically necessary for:

  • Patients with end-stage complications (such as renal failure).
  • Patients who are unable, because of, behavioral, psychological problems, or functional ability, to technically operate the pump and perform frequent blood glucose monitoring.
  • Patient convenience when control is achieved with multiple daily injections. 

Rationale

External subcutaneous insulin infusion pumps are considered medically necessary only for people who have demonstrated the ability and commitment to engage in a regimen of pump care, frequent self-monitoring of blood glucose and careful attention to diet and exercise.

The pump must be ordered by and follow-up care of the member must be managed by a physician with experience managing persons with insulin infusion pumps and who works closely with a team including nurses, diabetic educators and dieticians who are knowledgeable in the use of insulin infusion pumps.

Documentation of continued medical necessity of the external insulin infusion pump requires that the member be seen and evaluated by the treating physician at least every 6 months.

 

References:

  1. CMS Publication 100-3, Manual section number 280.14
  2. Interqual criteria accessed 10/2013 

 

Codes

Number

Description

HCPCS E0784 External ambulatory infusion pump, insulin  
ICD-9 Diagnosis  250-250.99 Diabetes Mellitus code range
ICD-10-CM (effective 10/1/14) E11.9, E11.319, E11.311, E11.8, E11.349, E11.341, E11.359, E11.351, E11.630, E11.69, E11.622, E11.628, E11.638, E11.39, E11.49, E11.29, E11.618, E11.59, E11.339, E11.331, E11.329, E11.321, E11.649, E11.641, E11.00, E11.01, E11.65, E11.621, E11.42, E11.51, E11.52., E11.40, E11.610, E11.21, E11.41, E11.620, E11.22, E11.36, E11.43, E11.44, E10.9, E10.319, E10.311, E10.8, E10.349, E10.341, E10.359, E10.351, E10.630, E10.69, E10.622, E10.628, E10.638, E10.39, E10.49, E10.29, E10.618, E10.59, E10.339, E10.331, E10.329, E10.321, E10.10, E10.11, E10.649, E10.641, E10.65, E10.621, E10.42, E10.51, E10.52, E10.40, E10.610, E10.21, E10.41, E10.620, E10.22, E10.36, E10.43, E10.44, E13.9, E13.319, E13.311, E13.8, E13.349, E13.341, E13.359, E13.351, E13.630, E13.69, E13.622, E13.628, E13.638, E13.39, E13.49, E13.29, E13.618, E13.59, E13.339, E13.331, E13.329, E13.321, E13.10, E13.11, E13.649, E13.641, E13.00, E13.01, E13.65, E13.621, E13.42, E13.51, E13.52, E13.40, E13.610, E13.21, E13.41, E13.620, E13.22, E13.36, E13.43, E13.44 Diabetes Mellitus code range


Policy History 

Date Action Reason
03/20/08 Add policy to Durable Medical Equipment section New local policy
06/03/08 Replace policy added documented TYpe I diabetes to description of adults in Policy section
12/11/08 Replace policy  removed investigational indications; not medically necessary indications added 
10/2013 Replace policy statement revised to include diabetes mellitus; removed type II specification