External Insulin Pump (E0784) Reimbursement Policy
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Defines medical necessity, coverage criteria, limitations, and prior authorization requirements for reimbursement of external insulin pumps (E0784, A9274, S1034) for University Health Alliance members.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Criteria
Medical necessity criteria for initial coverage
Coverage is provided when medical necessity and all listed criteria are met; exceptions for pregnancy and replacement are described.
ALL of the following
- Patient has a history of type 1 diabetes mellitus.
- Patient or caregiver has completed a comprehensive diabetes self-management education program, including instruction in carbohydrate counting.
- Patient or caregiver has demonstrated compliance and competence with an appropriate Type 1 diabetes insulin regimen for at least 3 months prior to the request, including: (a) multiple daily injections (≥3/day) with frequent self-adjustment of insulin doses based on glucose measurements and carbohydrate counting; (b) glucose self-testing 4–7 times per day with an average of at least 4 tests per day.
- Patient has suboptimal glycemic control despite an appropriate Type 1 diabetes insulin regimen. Examples include (but are not limited to): HbA1c > 7%; repeated and unpredictable hypoglycemia; wide fluctuations in preprandial blood glucose; dawn phenomenon with fasting blood sugars frequently > 200 mg/dL; or severe glycemic excursions.
- The external insulin pump is ordered and follow-up care will be provided by an endocrinologist or, if no endocrinologist is available, by a physician or licensed healthcare practitioner who manages multiple patients on continuous subcutaneous insulin infusion (CSII) therapy and works closely with a multidisciplinary team (nurses, diabetes educators, dietitians) knowledgeable in CSII.
HCPCS Codes and Key Coding Rules
| E0784 | External ambulatory infusion pump, insulin |
| A9274 | External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories |
| S1034 | Artificial pancreas device system (e.g., low glucose suspend [LGS] feature) including continuous glucose monitor, blood glucose device, insulin pump and computer algorithm that communicates with all the devices |
Prior Authorization and Submission Requirements
Prior authorization required; submit via UHA portal
Prior authorization is required for external insulin pumps. Submit the required documentation via UHA's online portal; if a portal login has not been established, contact UHA at 808-532-4000 to set one up.
- Include notes documenting type 1 diabetes and completion of comprehensive diabetes self-management education including carbohydrate counting.
- Include documentation of compliance with an appropriate type 1 insulin regimen and evidence of frequent self-adjustment and glucose self-testing (average ≥4 times/day in the 3 months prior to request).
- Include HbA1c results obtained within 3 months of the request.
Replacement pump prior authorization — treating physician must initiate
Prior authorization is required for replacement pumps and must be initiated and ordered by the treating physician. Submit documentation that the patient has continued to use the pump and that the pump is malfunctioning/out of warranty and cannot be repaired, or that newer technology is medically necessary, plus a recent HbA1c.
- Documentation that the pump is malfunctioning, out of warranty and cannot be repaired, or evidence that new technology or a special feature is medically necessary.
- Results of HbA1c obtained within three months of the replacement request.
- Replacement requests must be initiated and ordered by the treating physician and demonstrate the patient has continued to use the pump with documented benefit.
Device and Code Definitions
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