Chronic Intermittent Intravenous Insulin Therapy (CIIIT)

POLICY NUMBER

A.2.01.43

DESCRIPTION

Chronic intermittent intravenous insulin therapy (CIIIT) is a technique for delivering variable-dose insulin to diabetic patients with the goal of improved long-term glycemic control. Through an unknown mechanism, CIIIT is postulated to induce insulin-dependent hepatic enzymes to suppress glucose production.

Glucose Homeostasis

Insulin-mediated glucose homeostasis involves 3 primary functions which occur at 3 locations: 1) insulin secretion by the pancreas; 2) glucose uptake, primarily in the muscle, liver, gut, and fat; and 3) hepatic glucose production. In the fasting state, when insulin levels are low, most glucose uptake into cells is non-insulin mediated. Glucose uptake is then balanced by liver production of glucose. However, after a glucose challenge, insulin binds to specific receptors on the hepatocyte to suppress glucose production. Without this inhibition, marked hyperglycemia may result.

Medications for Glucose Homeostasis in Diabetes

Diabetes is characterized by elevated blood glucose levels due to inadequate or absent insulin production (type 1 diabetes) or due to increased hepatic glucose production, decreased peripheral glucose uptake, and decreased insulin secretion (type 2 diabetes).

Patients with type 1 diabetes require insulin therapy. Insulin therapy for patients with type 1 diabetes usually consists of multiple daily subcutaneous injections with both basal and mealtime insulin or continuous subcutaneous insulin infusions given through an insulin pump. Insulin therapy has improved over the last several decades with newer insulin products providing improved pharmacokinetic parameters to closer mimic physiologic insulin. Intravenous insulin is used in the acute inpatient setting to manage hyperglycemic emergencies (eg, diabetic ketoacidosis).

Any insulin infusion pump can be used for chronic intermittent intravenous insulin therapy. Infusion pumps have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. The FDA determined that this device was substantially equivalent to existing devices for the delivery of intravenous medications.

POLICY

Chronic intermittent intravenous insulin therapy is considered investigational.

POLICY EXCEPTIONS

Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.

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.

This policy does not apply to use of intravenous insulin infusions in the inpatient setting (ie, for the treatment of diabetic ketoacidosis or diabetic hyperosmolar coma).

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

5/2002: Approved by Medical Policy Advisory Committee (MPAC).

1/13/2004: Code Reference section updated, ICD-9 procedure code 99.17 deleted, ICD-9 diagnosis code range 250.00 - 250.93 listed separately.

03/10/2006: Coding updated. CPT4 revisions added to policy.

1/7/2009: Policy reviewed, no changes.

04/26/2010: Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. Added HCPCS code G9147.

10/21/2010: Policy reviewed; no changes.

09/23/2011: Policy reviewed. Policy description updated regarding techniques and devices; policy statement unchanged.

05/07/2013: Policy reviewed; no changes.

11/06/2013: Policy reviewed; no changes.

09/02/2014: Policy reviewed; description updated. Policy statement unchanged.

08/21/2015: Code Reference section updated for ICD-10.

10/28/2015: Policy description updated regarding diabetes and standard insulin management. Policy statement unchanged. Policy guidelines updated to state that this policy does not apply to use of intravenous insulin infusions in the inpatient setting (ie, for the treatment of diabetic ketoacidosis or diabetic hyperosmolar coma). Investigative definition updated.

03/30/2016: Policy description updated. Policy statement unchanged.

06/01/2016: Policy number A.2.01.43 added.

03/08/2017: Policy description updated regarding glucose homeostasis and chronic intermittent insulin therapy. Policy statement unchanged.

02/26/2018: Policy description updated. Policy statement unchanged.

03/19/2019: Policy description revised to remove information regarding the different forms of chronic intermittent insulin therapy. Policy statement unchanged.

03/06/2020: Policy reviewed; no changes.

04/01/2021: Policy description updated regarding insulin therapy for patients with type 1 diabetes. Policy statement unchanged.

04/06/2022: Policy reviewed; no changes.

03/13/2023: Policy reviewed; no changes.

03/11/2024: Policy reviewed; no changes.

04/09/2025: Policy description updated. Policy statement unchanged.

SOURCE(S)

Blue Cross Blue Shield Association policy # 2.01.43

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy. 

Investigational Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.