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)    Insulin pumps are covered for the treatment of Type 1 diabetics on a case-by-case basis.  They require pre-authorization.

2)    The Pre-authorization request for Insulin pump will require:

a)  Submission by the ordering provider office AND

b)  Accompanying patient medical records such as provider clinic progress notes. Information on vendor request forms is not acceptable.

3)    Portable external subcutaneous insulin pumps provide the administration of insulin by continuous infusion instead of intermittent injections to improve metabolic control in diabetics. 

4)    Insulin pumps make the ideal management of blood sugar easier in some diabetics, but they do not make blood sugar management easy, nor are they appropriate for everyone:

a)    People who achieve ideal blood sugar management on intermittent insulin do not require an insulin pump.

b)    People who are not conscientious in the management of their diabetes will generally not benefit from an insulin pump, since it still requires a considerable effort to self-manage diabetes.

1)    External insulin infusion pumps are covered for patients with insulin dependent diabetes (E10.10-E10.9) who meet the criteria set forth below.

2)    Insulin pumps require pre-certification and are implanted on an outpatient basis.  The pump must be ordered by and follow-up care of the patient must be provided by a physician with experience managing patients with insulin pumps and who works closely with a team including nurses, diabetic educators, and dieticians knowledgeable in the use of insulin pumps.

3)    QualChoice will provide coverage for supplies that are necessary for the effective use of the insulin pump.  Such supplies are covered under the DME benefit.

4)    QualChoice covers the insulin used in the insulin pump under the pharmacy benefit.

Preauthorization Criteria:

A. Standard Criteria: Patients must meet ALL of the following criteria:

1.     The patient has completed a comprehensive diabetes education program; and

2.     The patient has been on multiple daily injections of insulin (at least 3 per day – exceptions should be considered for children when compliance to multiple insulin doses may be a problem) with frequent self-adjustments of insulin dose for at least six (6) months prior to initiation of the insulin pump; and

3.     The patient has been self-testing for blood sugar on an average of at least four (4) times per day during  the two months prior to initiation of the insulin pump; and

4.     The patient meets one or more of the following criteria while on multiple daily injections of insulin:

·       Elevated glycosylated hemoglobin of 7.0 or greater; or

·       History of recurring hypoglycemia (less than 60mg/dL); or

·       Wide fluctuations in blood glucose before mealtime (pre-prandial blood glucose levels commonly exceeding 140mg/dL); or

·       Dawn phenomenon with fasting blood sugars frequently exceeding 200mg/dL; or

·       History of severe glycemic excursions.

B. Patients who are, or are anticipating being pregnant:

1.     The patient has a history of poor control without a pump during a previous pregnancy; or

2.     The patient meets the criteria in section A excepting duration of effort, or

3.     The patient was in good control prior to becoming pregnant, and has failed efforts to continue control during pregnancy.

C. Patients who have been using an insulin pump and request or require an upgrade or replacement pump:

1.     The previous pump is no longer functional (and is not repairable), but its use met the criteria above; or

2.     The previous pump was recalled by its manufacturer, in which case:

a.     We will expect the patient to use the manufacturer recall and replacement program.

b.     If the patient wishes to acquire a different brand of pump, we will allow toward that purchase only what we would have paid if the patient had used the manufacturer recall and replacement program.

3.     If the patient requests or requires replacement or upgrade of a fully functional insulin pump:

a.     If diabetic control is suboptimal to the point where the patient would qualify for a pump under section A, we will pay for the upgrade pump; otherwise

b.     If the pump is essentially for the convenience of the patient – meaning that control with the current pump is excellent, and cannot therefore be expected to improve with the change of pump – we will not pay for the upgrade or replacement pump.

c.     In pregnancy, an upgrade will be allowed if:

                                                    i.     There is poor control with the existing pump (there is no requirement for elevated hemoglobin A1c or for crisis, but only for significant difficulty in control), or

                                                   ii.     There is documentation of serious difficulty in control of diabetes during a prior pregnancy on the current pump.

Codes Used In This BI:

E0784           External ambulatory infusion pump, insulin

A9274           External ambulatory insulin delivery system, disposable

QualChoice reviews and authorizes services and substances. Billing and procedure codes change from time to time and QualChoice medical policies may not always reference the current published codes. This does not change the intent or effect of the policy language, nor does it affect the necessity for appropriate process. The codes are included in Medical Policies as a convenience to the readers of the policy.

Addendum:

1.     Effective 07/01/2017: added clarifying verbiage that Insulin pump requests will need to be submitted by ordering provider office along with provider’s clinic progress notes. Requests from Vendors or on vendor request forms will not be accepted.

2.     Effective 01/01/2018: Clarified verbiage that Supplies for an insulin pump do not require preauthorization.