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: 01/03/2024 |
Status: Reviewed | Last Review Date: 11/09/2023 |
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:
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
The therapeutic regimen is proven or generally accepted to have significant advantages over intermittent bolus administration regimens or infusions lasting less than 8 hours.
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.
When services may be Medically Necessary when criteria are met:
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 |
|
|
ICD-10 Diagnosis |
|
| All diagnoses |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.
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 (for example, intravenous, intramuscular, intraperitoneal).
References |
Government Agency, Medical Society, and Other Authoritative Publications:
Index |
External Infusion Pumps
History |
Status | Date | Action |
Reviewed | 11/09/2023 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description and References sections. |
Reviewed | 11/10/2022 | MPTAC review. Updated References section. |
Reviewed | 11/11/2021 | MPTAC review. Updated References section. |
Reviewed | 11/05/2020 | MPTAC review. Updated Clinical Indications section and changed “Physicians’ Desk Reference” to “Prescribers’ Digital Reference”. Updated References section. Reformatted Coding section; removed codes K0601-K0605. |
Reviewed | 11/07/2019 | MPTAC review. Updated References section. |
Reviewed | 11/08/2018 | MPTAC review. Updated Description, Definitions, and References sections. |
Reviewed | 01/27/2017 | 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 |
Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.
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