CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Chronic Intermittent Intravenous Insulin Therapy

This policy governs coverage determinations for chronic intermittent intravenous insulin therapy (CIITT) for diabetic patients and applies to Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyChronic Intermittent Intravenous Insulin Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2017

Next Review DateN/A

Key ActionVerify member benefits and applicable Evidence of Coverage before submitting claims because coverage varies by contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCoverage stance

G9147Specific code

InsufficientEvidence

2023Last review

Coverage Determination

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Primary coverage determination: Chronic intermittent intravenous insulin therapy is considered not covered / not medically necessary because the evidence is insufficient to determine the effects of the technology on health outcomes.

Applies to Commercial Products and Medicare Advantage as specified; small randomized and uncontrolled studies report only intermediate outcomes and clinical significance is uncertain.

The following code is designated as not covered for Medicare Advantage Plans and is considered not medically necessary for Commercial Products: HCPCS G9147 — "Outpatient intravenous insulin treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient, and/or, urine urea nitrogen (UUN)."

Chronic intermittent intravenous insulin therapy (CIITT) is considered not covered / not medically necessary because the available evidence is insufficient to determine the effects of the therapy on health outcomes. Small randomized and uncontrolled studies report only intermediate outcomes, and the collective evidence does not establish clinical benefit sufficient to support coverage.

Actions for Providers and Billing

Documentation Required

Benefit verification and member-specific documentation

Verify member-specific benefits and eligibility before providing services. Benefits may vary by group and contract; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage terms. Contact the provider call center for member-specific benefit questions.

Check Benefit Booklet / Evidence of Coverage / Subscriber Agreement for coverage determinations
Contact provider call center for member-specific benefits/eligibility

Prior Authorization

Prior authorization — verify member coverage documents

Prior authorization: Not applicable for this policy. However, prior authorization requirements may vary by product; always verify prior auth requirements on the member's contract and with the plan.

Policy-level prior authorization: Not applicable
Confirm prior authorization requirements on member-specific coverage documents

Step Therapy

Step therapy / clinical context

Intravenous insulin is reserved for acute inpatient management of hyperglycemic emergencies (e.g., diabetic ketoacidosis). Standard outpatient diabetes management uses subcutaneous insulin. Step-therapy/setting considerations: IV insulin is not a substitute for standard subcutaneous management in the ambulatory setting.

IV insulin: appropriate for acute inpatient hyperglycemic emergencies only
Standard management: subcutaneous insulin for routine outpatient care

Denial Risk

Coverage denial risk for CIITT

Coverage denial risk: Chronic intermittent intravenous insulin therapy (CIITT) is classified by this policy as not covered / not medically necessary due to insufficient evidence of benefit. Providers should be aware that services consistent with CIITT may be denied and, for some products, HCPCS G9147 is not covered for Medicare Advantage plans. Confirm member financial liability and obtain informed written consent if proceeding with noncovered services at the member's expense.

CIITT considered not covered / not medically necessary
HCPCS G9147: not covered for Medicare Advantage (MA) products — verify product-specific coverage
If service is not covered, do not bill member unless informed written consent obtained per subscriber agreement

Background

Chronic intermittent intravenous insulin therapy (also referred to as pulsatile intravenous insulin therapy or hepatic activation therapy) is an outpatient treatment in which insulin is delivered intravenously in a pulsatile fashion, typically once weekly over several hours using a pump. The approach is intended to increase portal insulin exposure to "reactivate" hepatic insulin‑dependent enzymes and thereby improve glycemic control. Evidence reviewed includes a small number of randomized controlled trials and uncontrolled studies that primarily report intermediate physiologic outcomes rather than demonstrated improvements in health outcomes.

Definitions

Definition: Chronic Intermittent Intravenous Insulin Therapy (CIITT)

TermChronic Intermittent Intravenous Insulin Therapy (CIITT)

DescriptionOutpatient therapy delivering insulin intravenously once weekly over several hours in a pulsatile fashion using a specialized pump programmed to adjust doses based on frequent blood glucose monitoring.

SynonymsOutpatient intravenous insulin therapy; pulsatile intravenous insulin therapy; hepatic activation therapy; metabolic activation therapy

Therapeutic intentDeliver higher, more physiologic concentrations of insulin to the liver than subcutaneous injections to 'reactivate' hepatic insulin-dependent enzymes and improve glucose control.

Delivery scheduleOnce weekly, over several hours, administered in pulsatile infusions.