INFUSION SERVICES AND EQUIPMENT
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Defines medical necessity, prior authorization, coding, and regulatory guidance for external and implantable infusion pumps and related supplies for Priority Health members; applies to clinical providers and DME suppliers contracting with the payer.
New Medical/Professional Society Guidelines, Government Regulations, Policy Scope, and FDA/Regulatory sections were added.
Clarified that external infusion pumps may be covered for certain conditions.
Exemptions for site of service review and a Medicaid MDHHS Provider Manual link regarding insulin pumps were deleted.
Coverage Criteria for Infusion Pumps
External Infusion Pumps - Covered Indications
External infusion pumps may be considered medically necessary for infusion of an FDA-approved drug when ALL of the following apply for listed conditions:
Conditions enumerated in policy
Insulin Pumps
Insulin pumps (commercial/Medicare):
See related policy 91466 for InterQual criteria
Implantable Infusion Pumps - Covered Indications and Exclusions
Implantable infusion pumps are covered when ALL specified conditions are met:
C2626 prior authorization not required
InterQual criteria apply
Two-option logic for liver cancer
Two required conditions
Explicit non-coverage
The policy explicitly states that the use of an implantable infusion pump to administer heparin for recurrent thromboembolic disease is not medically necessary because this use has not been proven to be safe or effective.
For Priority Medicaid members, the policy indicates that infusion supply codes A4221, A4222, and A4223 are not covered.
The policy lists codes C9804 and C9806 (elastomeric and rotary peristaltic infusion pumps and components) as not separately payable for Fully Funded and Self-Funded plans.
Coverage under this policy is subject to the member's specific benefits. When a group-specific or self-funded plan document conflicts with this policy, the provisions of that plan document will supersede the policy.
As stated elsewhere in the policy, the use of an implantable infusion pump to administer heparin for recurrent thromboembolic disease is not medically necessary because safety and effectiveness have not been established for that indication.
Coding — Codes Supporting Coverage and Billing
| G89.0 | Central Pain Syndrome |
| G89.21-G89.29 | Chronic pain due to trauma |
| G89.3 | Neoplasm related pain (acute) (chronic) |
| G89.4 | Chronic pain syndrome |
| R52 | Pain, unspecified |
| G90.50-G90.9 | Complex regional pain syndrome I |
| G95.11 | Acute infarction of spinal cord (embolic) (non-embolic) |
| G95.19 | Other vascular myelopathies |
| M08.1 | Juvenile ankylosing spondylitis |
| M45.0-M45.9 | Ankylosing spondylitis |
| 36260 | Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver) |
| 36261 | Revision of implanted intra-arterial infusion pump |
| 36262 | Removal of implanted intra-arterial infusion pump |
| 61215 | Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to Ventricular catheter |
| 62360 | Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir |
| 62361 | Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump |
| 62362 | Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump |
| 62365 | Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion |
| 62367 | Electronic analysis of programmable, implanted pump; without reprogramming or refill |
| 62368 | Electronic analysis of programmable, implanted pump; with reprogramming |
| No codes listed |
Provider Actions, Prior Authorization, and Billing Guidance
Prior Authorization Required
Prior authorization may be required for select external infusion pumps and implantable infusion pumps as determined by Priority Health's medical department. Providers must obtain PA when indicated before service to avoid claim denials or delayed payment.
- External infusion pumps: PA may be required for certain indications (see medical department determination).
- Implantable infusion pumps: PA may be required for specific indications; note that Code C2626 (infusion pump, nonprogrammable, temporary implantable) does not require prior authorization.
- Insulin pumps (Commercial/Medicare): Both new and replacement insulin pumps require prior authorization and must meet applicable InterQual criteria.
Plan-Determined Prior Authorization
Follow applicable plan documents for coverage and prior authorization requirements. For self-funded (ASO), individual, and commercial products, the member’s specific plan provisions supersede this policy where applicable.
- HMO/EPO/POS/PPO: This policy applies to insured plans; consult plan documents for state-mandated benefits.
- ASO (self-funded): Consult the employer’s plan document—those provisions govern if they conflict with this policy.
- INDIVIDUAL: Consult the individual insurance policy document for any conflicts.
Prior Authorization Documentation
When submitting a prior authorization request, providers must demonstrate medical necessity per Priority Health criteria and include supporting documentation. Use InterQual criteria where applicable and reference Priority Health Prism for the specific authorization criteria lookup.
- Access InterQual: Priority Health Prism → Authorizations → Authorization Criteria Lookup.
- Individual case review may be considered for investigational/promising treatments but requires prior plan approval by a medical director or clinical pharmacist.
Denial Risk if Prior Authorization Not Obtained
Failure to obtain required prior authorization may result in claim denial or nonpayment. Confirm PA requirements before providing pumps or related services.
- Lack of PA when required may trigger denial or retrospective review.
- Providers should verify PA requirements with Priority Health and the member’s plan prior to scheduling or delivering services.
Coding and Documentation for Michigan Medicaid
For Michigan Medicaid / Healthy Michigan Plan members, include appropriate procedure and supply codes on the Michigan Medicaid Fee Schedule and consult the Michigan Medicaid Provider Manual when discrepancies arise.
- Verify coverage and fee schedule coding with Michigan Medicaid Fee Schedule for DME/supplies.
- If conflict exists between this policy and the Michigan Medicaid Provider Manual, the Provider Manual governs; if guidance is lacking, the Priority Health contract with Michigan Medicaid governs.
Plan Benefit and Document Conflicts
This policy may be superseded by the specific benefit plan or self-funded plan document. When inconsistencies exist, the plan document or contract provisions govern coverage decisions.
- Group-specific policy provisions override this medical policy when applicable.
- Medicare coverage determinations by CMS take precedence when adopted.
Background and Scope
External infusion pumps deliver prescribed drugs by a variety of routes and may be stationary or ambulatory. Implantable infusion pumps are surgically implanted devices designed to provide long-term, site-specific drug delivery with constant or variable infusion rates. Both external and implantable systems are used to enable continuous or intermittent administration of medications for conditions such as chronic pain, spasticity, and certain chemotherapy applications, and may require preauthorization or meet specific clinical criteria to be considered medically necessary.
Definitions
DME Medical Necessity and Evidence Basis
DME Medical Necessity Criteria
DME medical necessity criteria mirror clinical coverage for pump types:
External pumps (except insulin) are rental only per coding section.
See implantable pump indications and exclusions.
Evidence-supported indications
Clinical evidence and guideline sources cited in the policy support indications for:
Guideline and evidence citations provided in policy references; see policy reference list for details.
Rental, Purchase, and Payment Rules
| Equipment | Rental vs Purchase / Payment Rule | Notes |
|---|---|---|
| External infusion pumps (except insulin) | ||
| rental | ||
| External pumps (except insulin pumps) are rental only per coding section; prior authorization may be required for certain indications and charge thresholds apply (see coding section). |
| Equipment | Rental vs Purchase / Payment Rule | Notes |
|---|---|---|
| Implantable infusion pumps (programmable and non-programmable; includes codes E0782, E0783, C1772, C1891, C2626) | ||
| neutral | ||
| Policy lists implantable pump HCPCS/C codes and replacement codes but does not specify rental vs purchase; certain implantable codes (e.g., C2626) noted elsewhere in policy regarding prior authorization exceptions. Coverage and payment may be subject to plan/CMS/Medicaid rules. |
| Item | Determination Source | Notes |
|---|---|---|
| Infusion pumps and related DME (supplies, elastomeric pumps, implantable systems) | ||
| Plan / CMS / State Medicaid rules determine payment | ||
| Coverage and payment are subject to the member's specific benefits and plan documents; Medicare coverage is determined by CMS; for Medicaid/Healthy Michigan Plan verify Michigan Medicaid Fee Schedule and Provider Manual. Specific coding and coverage notes for supplies (A4221–A4223) and certain device codes (C9804, C9806) are included in coding section. |
Replacement, Repairs, and Intraspinal Catheters
Documentation Requirements
Clinical justification and supporting documentation required
Provide clinical justification and supporting documentation demonstrating medical necessity when submitting a prior authorization request for infusion pumps or related DME.
- Include relevant clinical history, diagnostic findings, prior treatments, and trial responses that support the requested device or service.
- Reference InterQual criteria via Priority Health Prism as applicable to support medical necessity determinations.
Verify fee schedule coding and medical necessity for Michigan Medicaid
For Michigan Medicaid/Healthy Michigan Plan members, include the appropriate code(s) from the policy's coding section on the Michigan Medicaid Fee Schedule and verify that those codes meet medical necessity criteria per the fee schedule.
- Verify Medical Supplies/DME/Prosthetics and Orthotics coverage on the Michigan Medicaid Fee Schedule.
- If discrepancies exist, follow the Michigan Medicaid Provider Manual or the Priority Health contract with Michigan Medicaid as specified.
Services and Items Not Covered
The following items and uses are explicitly not covered: implantable infusion pump administration of heparin for recurrent thromboembolic disease (not medically necessary), and selected infusion supply codes noted as not covered for certain member types—specifically, A4221, A4222, and A4223 for Priority Medicaid. Additionally, certain pump device codes may have separate-payability restrictions depending on plan funding type (see coding section).
Inventory statements preserved from the policy reiterate that the implantable pump for heparin delivery is not medically necessary and that supplies coded A4221–A4223 are not covered for Priority Medicaid; these exclusions are maintained as policy not-covered items.
When plan documents differ, services excluded under the member's plan or a self-funded plan are not covered under this policy. In other words, the member's specific benefit plan or self-funded plan document governs and will supersede this policy where conflicts exist.
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