Infusion Pump/Supplies

Ambulatory Infusion Pump

Coverage criteria:

• Administration of deferoxamine for treatment of acute iron poisoning and iron overload;
• Administration of heparin in treatment of thromboembolic disease and/or pulmonary embolism; this application is for patients requiring long-term anticoagulation therapy who have previously been stabilized and are on a maintenance dose of heparin;
• Total parenteral nutrition or enteral nutrition;
• Breast, lung, primary hepatocellular carcinoma, or colorectal cancer; individual consideration given to other cancers.
• Administration of antibiotics

External Ambulatory Infusion Pump, Insulin Pump, Insulin

Click here to view the medical policy External Ambulatory Infusion Pump, Infusion Pump, Insulin

Implantable Infusion Pump (Nonprogrammable)

Implantable infusion pumps are surgically implanted into the subcutaneous tissue of the abdomen and the delivery catheter is threaded into the appropriate vessel in order to provide long-term continuous administration of drugs.

This is part of the facility charge and is not covered in the home setting when billed by a DME company.

Implantable Infusion Pump (Programmable)

This is part of the facility charge and is not covered in the home setting when billed by a DME company.

Parenteral Infusion Pump, Stationary, Single or Multi-channel: E0791

An external infusion pump is a device that provides continuous infusion of medication in the treatment of a number of diseases. It is attached to a needle or catheter that provides continuous infusion of certain agents such as cancer chemotherapy drugs, insulin, heparin, or antibiotics.

A parenteral infusion pump (stationary, single or multi-channel) is covered for the following:

• Thromboembolic disease when used in the administration of heparin for the treatment of thromboembolic disease and/or pulmonary embolism;
• Total parenteral or enteral nutrition when there is a loss of a sufficient amount of the small intestine or absorptive surface of the small intestine which depletes the nutritional state;
• Chemotherapy for cancer when used in the treatment of breast, lung, primary hepatocellular carcinoma, or colorectal cancer where this disease is unresectable or where the patient refuses surgical excision of the tumor; other uses must be reviewed by Medical Review on an individual basis for coverage;
• Narcotics for intractable cancer pain for the infusion of morphine via an external infusion pump when used in the treatment of intractable pain caused by cancer (in either an inpatient or outpatient setting, including a hospice);
• Antibiotic administration for the infusion of antibiotics via an external infusion pump when used in the treatment of infectious diseases.

Personal Therapy Manager

A Personal Therapy Manager is a handheld device that works with the SynchroMed Pain Pump. This device allows you to request an additional dose/bolus of medication from your implanted pump that has been programmed by you doctor. This device does not meet medical criteria for coverage.