CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Chronic Intermittent Intravenous Insulin Therapy (CIIIT / OIVIT)

Defines coverage stance for chronic intermittent intravenous insulin therapy (also called outpatient intravenous insulin treatment, pulsatile intravenous insulin therapy) for commercial and Medicare products, including coding and rationale. States medical necessity determinations and that prior authorization is not applicable.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyChronic Intermittent Intravenous Insulin Therapy (CIIIT / OIVIT)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2017

Next Review Date

Key ActionVerify member benefits and applicable contract language (Evidence of Coverage/Subscriber Agreement) because benefits may vary between groups and contracts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

1Primary HCPCS code listed

2Product stances (Medicare, Commercial)

Coverage Summary

Overview: Chronic Intermittent Intravenous Insulin Therapy (CIIIT / OIVIT) is addressed in this policy with an overall coverage stance of not_covered_cosmetic. For BlueCHiP for Medicare the therapy is not covered, and for Commercial Products the therapy is considered not medically necessary because the evidence is insufficient to determine effects on health outcomes. Effective date: 2017-05-01. Policy last reviewed: 2018-07-17.

Policy Metadata

Effective Date2017-05-01

Last Review2018-07-17

Next Review

StatusCURRENT

SubjectChronic Intermittent Intravenous Insulin Therapy (CIIIT / OIVIT)

Scope SummaryDefines coverage stance for chronic intermittent intravenous insulin therapy (also called outpatient intravenous insulin treatment, pulsatile intravenous insulin therapy) for commercial and Medicare products, including coding and rationale. States medical necessity determinations and that prior authorization is not applicable.

Medical Necessity / Coverage Determinations

Coverage Determination by Product

Coverage statements for Chronic Intermittent Intravenous Insulin Therapy (CIIIT):

ALL of the following

BlueCHiP for Medicare: Chronic intermittent intravenous insulin therapy is considered not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products: Chronic intermittent intravenous insulin therapy is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

Provider Actions

Documentation Required

Benefit verification

Verify member benefits and applicable contract language (Evidence of Coverage/Subscriber Agreement) because benefits may vary between groups and contracts.

Denial Risk

Service not covered / not medically necessary

Claims for chronic intermittent intravenous insulin therapy (including code G9147) are not covered for BlueCHiP for Medicare and are considered not medically necessary for Commercial Products; expect denial/claim rejection per contract.

G9147

Prior authorization: Not applicable.

Background & Evidence

Background: Chronic Intermittent Intravenous Insulin Therapy (also called outpatient intravenous insulin treatment, pulsatile intravenous insulin therapy, hepatic activation therapy, or metabolic activation therapy) is an outpatient technique delivering pulsatile or continuous intravenous insulin, typically administered intermittently (eg, once weekly) over several hours to target hepatic insulin exposure and attempt to normalize hepatic glucose metabolism. Evidence for CIIIT consists of small randomized controlled trials and uncontrolled studies reporting changes in intermediate outcomes; overall the published evidence is limited, small, primarily dated (most evidence published between 1993 and 2000), and insufficient to determine clinical benefit.

Evidence Item	Summary
Randomized controlled trials	Two small RCTs reported potential moderation of nephropathy or retinopathy but clinical significance uncertain
Evidence timeframe	Most published evidence between 1993 and 2000; does not reflect more recent diabetes care advances
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Definition: Chronic Intermittent Intravenous Insulin Therapy (CIIIT) — outpatient intravenous insulin therapy (pulsatile or continuous) administered intermittently (eg, once weekly) to target hepatic insulin exposure; also referred to as outpatient intravenous insulin treatment (OIVIT), pulsatile intravenous insulin therapy, hepatic activation therapy, or metabolic activation therapy.

OpenPayer

Chronic Intermittent Intravenous Insulin Therapy (CIIIT / OIVIT)

Coverage Summary

Medical Necessity / Coverage Determinations

Coding

Provider Actions

Background & Evidence