Coverage Policies

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INDEX:

Effective Date: 02/01/2012

Title: External Infusion Pumps

Revision Date:

Document: BI319:00

CPT Code(s): E0781, E0784

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1) External infusion pumps (EIP) are covered for the administration of drugs for the following conditions:

a) Treatment of severe, chronic cancer pain that is resistant to conventional therapy;

b) Treatment of insulin-dependent diabetes mellitus in patients who cannot be controlled by intermittent dosing;

c) Treatment of severe thromboembolic disease that cannot be managed conventionally (e.g., complicated pregnancy);

d) Chemotherapeutics for treatment of cancer;

e) Treatment of chronic spasticity problems.

2) EIP require prior authorization.

3) Use of EIP for administration of insulin is discussed in BI041, Insulin Pumps.

4) Use of EIP for parenteral nutrition is covered when parenteral nutrition has been pre-authorized.

5) Uses of EIP for intralesional administration of analgesics or anesthetics are not covered; see BI243.

Medical Statement

1) Use of the EIP for the administration of the following drugs is considered medically necessary and is covered 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);
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 might be IV or intra-arterial.

2) Patient selection is key to appropriate utilization of the EIP. Factors relevant to the selection of EIP candidates may include several of the following conditions:

a. Patient is ambulatory and treatment can be appropriately delivered on an outpatient basis, with an expected improvement in the quality of life

b. Drug therapy is ongoing and a therapeutic advantage is expected by using continuous (or pulsatile) infusion rather than intermittent injections;

c. Patient is otherwise treatable only by conventional infusion pump in an institutional setting, or compliance difficulties make intermittent injection ineffective;

d. Patient education protocols are documented and emergency support is available when unexpected adverse events occur; and

e. Presence of favorable technical factors, such as a convenient, safe, and reliable EIP delivery system along with correct placement of the needle and catheter, exist.

Codes Used In This BI:

E0781	Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient
E0784	External ambulatory infusion pump, insulin

Limits

1) EIP are subject to DME benefit limits.

2) Pumps are expected to last through their warranty life. They will be replaced within that time period only for extraordinary circumstances. Misuse is not covered.

Application to Products

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.