Clinical UM Guideline

 

Subject: External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings
Guideline #:  CG-DME-21 Publish Date:    03/29/2018
Status: Reviewed Last Review Date:    02/27/2018

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) is 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

E0776

IV pole

E0779

Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater

E0780

Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours

E0781

Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient

E0791

Parenteral infusion pump, stationary, single or multi-channel

 

 

 

Supplies

A4221

Supplies for maintenance of drug infusion catheter, per week (list drug separately)

A4222

Supplies for external drug infusion pump, per cassette or bag (list drug separately)

K0552

Supplies for external drug infusion pump, syringe type cartridge, sterile, each

K0601

Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each

K0602

Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each

K0603

Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

K0604

Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each

K0605

Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each

 

 

ICD-10 Diagnosis

 

 

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 October 31, 2017.
    • 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 31, 2015. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/203952s000lbl.pdf. Accessed on October 31, 2017.
Index

External Infusion Pumps

Document History

Status

Date

Action

Reviewed

01/27/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.”

Revised

02/02/2017

MPTAC review. Made minor typographical revision to Clinical Indications. Updated References section.

Revised

02/04/2016

MPTAC review. Minor language clarification made in Medically Necessary Section. Removed ICD-9 codes from Coding section.

Revised

02/05/2015

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 References sections.

Reviewed

08/14/2014

MPTAC review.

Reviewed

11/14/2013

MPTAC review.

Reviewed

11/08/2012

MPTAC review. Updated References section.

Reviewed

11/17/2011

MPTAC review. Updated References section.

Reviewed

11/17/2010

MPTAC review. Updated References section.

Reviewed

11/19/2009

MPTAC review. Updated References section.

Reviewed

11/20/2008

MPTAC review.

Reviewed

11/29/2007

MPTAC review. References updated. Minor formatting changes.

Reviewed

12/07/2006

MPTAC review. References updated.

New

12/01/2005

MPTAC initial guideline development.

Pre-Merger Organizations

Last Review Date

Document Number

Title

 

Anthem, Inc.

 

 

No document

Anthem CO/NV

10/29/2004

DME.217

External Infusion Pumps