CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Chronic Intermittent Intravenous Insulin Therapy (CIITT) Coverage Criteria

This policy governs coverage and medical necessity determinations for chronic intermittent intravenous insulin therapy (also called pulsatile/outpatient IV insulin) for members of Blue Cross Blue Shield - Rhode Island across Commercial and Medicare (BlueCHiP) products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyChronic Intermittent Intravenous Insulin Therapy (CIITT) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2017

Next Review DateN/A

Key ActionVerify member benefits and coverage before providing CIITT; prior authorization is not applicable but benefits may vary by contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredBlueCHiP for Medicare stance

Not medically necessaryCommercial product stance

1Coding entries

LimitedEvidence base

Coverage Determinations

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Coverage determination

Covered when ALL of the following are met:

BlueCHiP for Medicare: CIITT is considered not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.

See coverage statement for BlueCHiP for Medicare.

Commercial Products: CIITT is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

See coverage statement for Commercial Products.

Evidence summary

RCTs and observational data: Two RCTs and multiple uncontrolled studies exist but report mainly intermediate laboratory outcomes and small sample sizes.
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Outpatient intravenous insulin treatment represented by HCPCS code G9147 (Outpatient intravenous insulin treatment — pulsatile or continuous) is explicitly not covered under BlueCHiP for Medicare. For Commercial products the same service is considered not medically necessary. This determination follows the policy statement that the evidence is insufficient to determine the effects of this technology on health outcomes and therefore the code is listed as not covered/not medically necessary in the coding section.

Claims submitted with G9147 for chronic intermittent intravenous insulin therapy (CIITT) will be denied/not paid under BlueCHiP for Medicare and will be denied as not medically necessary under Commercial products in accordance with this policy.

For Commercial products the policy finds the evidence base inadequate to support CIITT. The available literature includes two randomized controlled trials and uncontrolled studies, but the published trials were small, reported only intermediate outcomes (for example laboratory measures), and did not demonstrate clear clinical benefit.

Because most studies predate recent advances in diabetes care and the clinical significance of reported differences is uncertain, the evidence is judged insufficient to show improved health outcomes; therefore CIITT is considered not medically necessary for Commercial members.

Billing / Coding

Not covered / Not medically necessary codeHCPCSNot Covered

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), and/01, arterial, venous Or capillary glucose, and/or potassium concentration

Not covered / Not medically necessary code (plain)HCPCSNot Covered

G9147

Provider Actions & Billing Impact

Prior Authorization

Prior authorization: Not applicable — verify benefits

Prior authorization is not required for chronic intermittent intravenous insulin therapy under this policy; however, coverage may vary by contract, so confirm member-specific benefits before providing services.

Step Therapy

Step therapy context — CIITT is distinct from standard care

CIITT is not part of standard diabetes step therapy; standard management uses subcutaneous insulin and guideline-directed therapies, whereas CIITT is an outpatient intravenous pulsatile therapy distinct from routine care.

Documentation Required

Verify member benefits and eligibility

Benefits and eligibility depend on the member’s subscriber agreement, Evidence of Coverage, or employer contract; contact the provider call center or refer to the member’s Benefit Booklet to verify coverage before delivering services.

Denial Risk

Denial risk — CIITT not covered/medically unnecessary by product

Claims for chronic intermittent intravenous insulin therapy will be denied/not paid under BlueCHiP for Medicare (not covered) and will be denied/considered not medically necessary for Commercial products.

Background

Chronic intermittent intravenous insulin therapy (CIITT) is an outpatient therapy that delivers insulin intravenously in a pulsatile fashion, typically administered once weekly over several hours using a pump and glucose monitoring. The approach is intended to raise portal insulin concentrations and stimulate hepatic insulin-dependent enzymes to improve glucose metabolism.

Standard diabetes management relies on subcutaneous insulin and other guideline-directed therapies; CIITT is a distinct, nonstandard outpatient intravenous insulin delivery method that has been evaluated in small randomized and uncontrolled studies but lacks robust evidence of clinically meaningful benefit.

Definitions

Definition — Chronic intermittent intravenous insulin therapy (CIITT)

Delivery methodIntravenous (pulsatile) infusion using a specialized pump controlled by a computerized program

Frequency & durationOnce weekly infusions delivered over several hours

Infusion patternPulsatile dosing designed to deliver higher, physiologic insulin concentrations to the liver than subcutaneous injections

Monitoring & controlDoses adjusted based on frequent blood glucose monitoring during the outpatient infusion

Therapeutic intentIncrease portal insulin concentrations to stimulate hepatic insulin‑dependent enzymes and improve hepatic glucose metabolism