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Printer Friendly Version External Infusion Pumps

External Infusion Pumps

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. They are battery-driven devices.

Proposed drug delivery routes using the EIP include the intravenous, intra-arterial, subcutaneous, 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.

OmniPod® is an external insulin pump sold by Insulet Corporation. This device has two separate components, a disposable "Pod" affixed to the skin that acts as the insulin pump and reservoir and a hand-held control unit referred to as a Personal Diabetes Manager or "PDM". The PDM also incorporates a FreeStyle blood glucose monitor (not continuous).

POLICY

Use of the external infusion pump (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).

The OmniPod® external insulin pump includes a FreeStyle blood glucose monitor. Therefore, a separate glucometer is not elgible for coverage with the use of this system.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

9/1992: Approved by Medical Policy Advisory Committee (MPAC)

11/1997: Review and update approved by MPAC

2/27/2002: Managed Care Requirements deleted

4/26/2002: Type of Service and Place of Service deleted

5/28/2002: Code Reference section updated

11/5/2003: Code Reference section updated, HCPCS A4230-A4232 listed separately

9/24/2004: Code Reference section updated, CPT code 62350, 62351, 62355 added, ICD-9 procedure code 03.90 added, ICD-9 diagnosis code 140 4th digit added 140.0, ICD-9 diagnosis 208.9 5th digit added 208.91, HCPCS A4222, A4230, A4231, A4232 “Note: See the Durable Medical Equipment medical policy for BCBSMS’ guidelines regarding accessories and medical supplies necessary for the effective functioning of covered durable medical equipment.” added, HCPCS A4632 added, K0552, K0601, K0602, K0603, K0604, K0605 added

3/24/2006: Coding updated. CPT4 2006 revisions added to policy

3/28/2006: Policy reviewed, no changes

12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions

12/17/2007: Coding updated. CPT/HCPCS 2008 revisions added to policy

7/21/2009: Description section updated to include OmniPod® information; policy statement updated to include separate glucometers are ineligible for coverage with the OmniPod® system. Code reference section updated: HCPC code E1399 added to covered table; notes added to codes A9274 and E0784.

SOURCE(S)

A search of 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

TEC Evaluations 1989: p. 59

Hayes Medical Technology Directory

Uniform Medical Policy Manual, 4/1990

Blue Cross Blue Shield Association policy #1.01.08

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a053532.htm

CODE REFERENCE

This is not intended to be a comprehensive list of codes. Note that some codes may be variable, and coverage will be based on the clinical indication for the service.

Covered Codes

Code Number	Description
CPT-4
62350	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy (added 9-24-2004)
62351	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy (added 9-24-2004)
62355	Removal of previously implanted intrathecal or epidural catheter (added 9-24-2004)
96521	Refilling and maintenance of portable pump (new 1-1-2006)
ICD-9 Procedure
03.90	Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances (added 9-24-2004)
ICD-9 Diagnosis
	Morphine; see pain for specific body part
140.0 - 208.91	Malignant neoplasms code range (description revised 11-5-2003) (ICD-9 140 4th digit added, ICD-9 208.9 5th digit added 9-24-2004)
250.03, 250.13, 250.23, 250.33, 250.43, 250.53, 250.63, 250.73, 250.83, 250.93	Insulin-dependent diabetes, uncontrolled code range
444.0, 444.1	Embolism and thrombosis of abdominal aorta code range (added 11-5-2003)
444.21, 444.22	Embolism and thrombosis of arteries of upper extremity code range (added 11-5-2003)
444.81	Embolism and thrombosis of iliac artery (added 11-5-2003)
444.89	Embolism and thrombosis of other specified artery (added 11-5-2003)
444.9	Embolism and thrombosis of unspecified artery (added 9-24-2004)
671.20, 671.21, 671.22, 671.23, 671.24	Superficial thrombophlebitis complicating pregnancy and the puerperium, unspecified as to episode of care code range (added 11-5-2003)
671.30, 671.31, 671.33	Deep phlebothrombosis, antepartum, code range (added 11-5-2003)
671.40, 671.42, 671.44	Deep phlebothrombosis, postpartum, code range (added 11-5-2003)
671.50, 671.51, 671.52, 671.53, 671.54	Other phlebitis and thrombosis complicating pregnancy and the puerperium, code range (added 11-5-2003)
671.80, 671.81, 671.82, 671.83, 671.84	Other venous complication of pregnancy and the puerperium, code range (added 11-5-2003)
671.90, 671.91, 671.92, 671.93, 671.94	Unspecified venous complication of pregnancy and the puerperium, code range (added 11-5-2003)
673.00, 673.01, 673.02, 673.03, 673.04	Obstetrical air embolism code range (added 11-5-2003)
673.10, 673.11, 673.12, 673.13, 673.14	Amniotic fluid embolism code range (added 11-5-2003)
673.20, 673.21, 673.22, 673.23, 673.24	Obstetrical blood-clot embolism code range (added 11-5-2003)
673.30, 673.31, 673.32, 673.33, 673.34	Obstetrical pyemic and septic embolism code range (added 11-5-2003)
673.80, 673.81, 673.82, 673.83, 673.84	Other obstetrical pulmonary embolism code range (added 11-5-2003)
HCPCS
A4222	Supplies for external drug infusion pump, per cassette or bag (list drug separately) Note: See the Durable Medical Equipment medical policy for BCBSMS’ guidelines regarding accessories and medical supplies necessary for the effective functioning of covered durable medical equipment. (added 9-24-2004)
A4230	Infusion set for external insulin pump, nonneedle cannula type Note: See the Durable Medical Equipment medical policy for BCBSMS’ guidelines regarding accessories and medical supplies necessary for the effective functioning of covered durable medical equipment. (added 9-24-2004)
A4231	Infusion set for external insulin pump, needle type Note: See the Durable Medical Equipment medical policy for BCBSMS’ guidelines regarding accessories and medical supplies necessary for the effective functioning of covered durable medical equipment. (added 9-24-2004)
A4232	Syringe with needle for external insulin pump, sterile, 3cc Note: See the Durable Medical Equipment medical policy for BCBSMS’ guidelines regarding accessories and medical supplies necessary for the effective functioning of covered durable medical equipment. (added 9-24-2004)

A9274	External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories (new 1-1-2008) Note: Use this code to report the "Pod" component of the Omnipod® infusion system. Use code E1399 to report the PDM component.
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, with administrative equipment, worn by patient
E0784	External ambulatory infusion pump, insulin Note: This code should not be used to report the Omnipod® infusion system. See codes E1399 and A9274
E1399	Durable medical equipment, miscellaneous Note: This code should be used to report the Personal Diabetes Manager (PDM) component of the Omnipod® infusion system. Use code A9274 to report the "Pod" component.
K0552	Supplies for external drug infusion pump, syringe type cartridge, sterile, each (effective 4-1-2003) (added 9-24-2004) Note: See the Durable Medical Equipment medical policy for BCBSMS’ guidelines regarding accessories and medical supplies necessary for the effective functioning of covered durable medical equipment.
K0601	Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each (effective 4-1-2003) (added 9-24-2004)
K0602	Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each (effective 4-1-2003) (added 9-24-2004)
K0603	Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each (effective 4-1-2003) (added 9-24-2004)
K0604	Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each (effective 4-1-2003) (added 9-24-2004)
K0605	Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each (effective 4-1-2003) (added 9-24-2004)

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