External Infusion Pumps

This sections/documents addresses the use of external infusion pumps in the home or residence setting for diagnoses other than diabetes or pulmonary hypertension.



External Infusion Pumps PDF Print E-mail
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Tuesday, 28 September 2010 16:50

Description

This document addresses the use of external infusion pumps in the home or residence setting for diagnoses other than diabetes or pulmonary hypertension.

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) are met:

Criteria set 1

  • Parenteral administration of the drug in the home is reasonable and necessary
  • An infusion pump is necessary to safely administer the drug
  • The drug is administered by a prolonged infusion of at least 8 hours because of proven improved clinical efficacy
  • 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

  • Parenteral administration of the drug in the home is reasonable and necessary
  • An infusion pump is necessary to safely administer the drug
  • The drug is administered by intermittent infusion (each episode of infusion lasting less than 8 hours) that does not require the individual to return to the physician's office prior to the beginning of each infusion
  • Systemic toxicity or adverse effects of the drug are unavoidable without infusing it at a strictly controlled rate as indicated in the Physicians Desk Reference.

Not Medically Necessary:

External infusion pumps and related supplies are considered not medically necessary when the criteria described above are not met.

Discussion/General Information

An ambulatory infusion pump is an electrical or battery operated device that is used to deliver solutions containing a parenteral drug under pressure at a regulated flow rate. It is small, portable, and designed to be carried by the patient.

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 parenteral 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 patient. It must be capable of a single infusion cycle of at least 8 hours.

This Clinical UM Guideline is based on Medicare criteria.

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-9 Diagnosis
All diagnoses

Last Updated on Monday, 24 January 2011 18:04