Summary & Overview
HCPCS Level II J1813: Insulin (Lyumjev) for Insulin Pump, per 50 Units
HCPCS Level II code J1813 designates Lyumjev insulin packaged for use with durable medical equipment (DME), billed per 50 units for administration through an insulin pump. This code matters nationally as pump-delivered rapid-acting insulin is a key component of insulin pump therapy for people with type 1 and insulin-dependent type 2 diabetes; accurate coding affects pharmacy and DME billing, patient access, and payer coverage decisions.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, and Medicare. Readers will find a concise overview of what J1813 represents, typical sites of service, and the clinical context for pump-based insulin delivery. The publication outlines payer coverage landscapes and common billing considerations relevant to pharmacy-DME coordination.
The report provides benchmarks and policy-relevant items such as how J1813 is used in claims for pump-supplied insulin, common reasons for claim denials or prior authorization requirements, and implications for billing workflows between pharmacies and DME suppliers. Clinical context covers why rapid-acting insulin formulations are used in pumps and how unit-based billing per 50 units maps to supply dispensing and claim lines.
Data limitations: Data not available in the input for associated taxonomies, specific ICD-10 pairings, and related codes.
Billing Code Overview
HCPCS Level II code J1813 describes insulin (lyumjev) for administration through durable medical equipment (DME), per 50 units. This code covers the medication product when supplied for use in an insulin pump or other DME infusion system.
Service type: Pharmacy-supplied injectable medication for pump-based insulin delivery
Typical site of service: DME setting / outpatient infusion via insulin pump
Clinical & Coding Specifications
Clinical Context
A 34-year-old patient with type 1 diabetes mellitus uses an insulin infusion pump (durable medical equipment) for continuous subcutaneous insulin delivery. The patient receives a monthly supply of rapid-acting insulin formulated as Lyumjev for pump use. At a scheduled outpatient diabetes clinic visit, the endocrinology nurse confirms pump settings, reviews glucose logs and continuous glucose monitor data, and documents a prescription refill for J1813 billed per 50 units of Lyumjev for pump reservoir loading. The pharmacy or DME provider dispenses the insulin to be used in the pump; administration occurs by the patient at home via the insulin pump. Typical workflow steps: patient assessment and glucose review; prescription/authorization for pump-compatible Lyumjev; DME/pharmacy fill and delivery; patient education on reservoir filling and infusion set insertion; ongoing remote or in-person pump management and periodic supply replacement. Typical site of service is outpatient clinic, specialty endocrinology office, home use with DME supply, or outpatient pharmacy supplying DME-delivered insulin.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier | Standard reporting when no modifier applies to the service. |