Insulin Pump
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Defines Blue Cross and Blue Shield of Kansas coverage criteria and coding guidance for external insulin infusion pumps for members, including prerequisites, clinical considerations, and coding lists. Applies to BCBSKS members and providers managing insulin pump therapy.
No material clinical or coverage changes in this revision.
Coverage Criteria for External Insulin Infusion Pumps
inv-01: Prerequisites
Covered when ALL of the following prerequisites are met:
From policy prerequisites A.1.
From policy prerequisites A.2; aligns with step-therapy requirement.
From policy prerequisites A.3.
From policy prerequisites A.4.
From policy prerequisites A.5.
inv-02: Clinical considerations supporting pump therapy
Consideration will be given when ONE OR MORE of the following clinical situations are present (when not explained by noncompliance):
From policy considerations B.1.
From policy considerations B.2.
From policy considerations B.3.
From policy considerations B.4.
From policy considerations B.5.
From policy considerations B.6.
From policy considerations B.7.
This policy previously included an explicit not medically necessary statement for morbidly obese (BMI ≥35) Type II diabetics with evidence of insulin resistance. That clause was added in revisions dated 12-14-2012 and later removed per the 03-31-2016 revision, so it is documented as a historical policy position rather than current coverage language.
The document now frames the limitation as an administrative consideration rather than a standing clinical "not medically necessary" exclusion. Coverage determinations continue to be contingent on the plan member's contract benefits and applicable state or federal mandates; providers are advised to verify member benefits and submit predetermination requests when coverage is uncertain.
Coding and Diagnosis References
| A4226 | Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week. |
| E0784 | External ambulatory infusion pump, insulin. |
| E0787 | External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing. |
| S9145 | Insulin pump initiation, instruction in initial use of pump (pump not included) |
| E10.10-E13.8 | Diabetes mellitus code range (document lists multiple specific E10, E11, E13 codes and pregnancy O24 codes). |
| O24.011 | Pre-existing type 1 diabetes mellitus, in pregnancy, first trimester. |
| O24.012 | Pre-existing type 1 diabetes mellitus, in pregnancy, second trimester. |
| O24.013 | Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester. |
Provider Actions, Documentation, and Authorization
Verify member benefits and predetermination
Benefits for an insulin pump are considered only when the policy prerequisites and clinical considerations are met; verify the member's contract benefits in effect at the time of service and submit a predetermination request as needed prior to obtaining the pump.
- Check member contract benefits and applicable state/federal mandates before proceeding.
- Submit a predetermination request or contact BCBSKS customer service or professional relations if coverage is uncertain.
Prior multiple daily injections: ≥4/day for ≥6 months (exceptions for pregnancy)
The member must have been on multiple daily injections with self-adjustments of insulin for at least 6 months, using a regimen of at least four injections per day; this requirement may be met earlier for pregnancy or preconception.
- Document duration (≥6 months) and that regimen included ≥4 injections/day with self adjustments.
- If seeking an exception for pregnancy or preconception, document timing and clinical rationale.
Provide order and clinical rationale in the record
The ordering provider's written order and the clinical rationale for insulin pump therapy must be included in the clinical record or provided as a letter from the ordering provider.
- Include documentation of the specific clinical indications that meet policy prerequisites or considerations.
- Retain the order/letter in the member's chart to support medical necessity determinations.
Contract, predetermination, and documentation required — lack may lead to denial
Coverage is subject to the member's contract benefits and required documentation; failure to verify benefits, submit predetermination when appropriate, or provide required documentation and prerequisites may result in non-coverage or denial.
- Ensure all prerequisites (education, injection history, self-testing frequency, ability to comply, and experienced ordering provider) are documented.
- Submit predetermination when coverage is uncertain and provide requested documentation to avoid denial.
Background
An external insulin infusion pump is a small, battery-operated device worn on the body and attached to a catheter that provides continuous subcutaneous insulin infusion to manage insulin delivery for patients with diabetes. Benefits for pump therapy are considered under the policy's prerequisites and clinical considerations and must be ordered and managed by a provider experienced with insulin pumps.
Definitions
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