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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that an external infusion pump is covered for administration of continuous subcutaneous insulin
for the treatment of diabetes mellitus if criterion A or B is met and if criterion C or D is met:
A. C-peptide testing requirement - must meet criterion 1 or 2 and criterion 3:
1. C-peptide level is less than or equal to 110 percent of the lower limit of normal of the
laboratory's measurement method.
2. For beneficiaries with renal insufficiency and a creatinine clearance (actual or calculated from
age, weight, and serum creatinine) less than or equal to 50 ml/minute, a fasting C-peptide level is less than or
equal to 200 per cent of the lower limit of normal of the laboratory's measurement method.
3. A fasting blood sugar obtained at the same time as the C-peptide level is less than or equal to
225 mg/dl.
B. Beta cell autoantibody test is positive.
C. The beneficiary has completed a comprehensive diabetes education program, has been on a program
of multiple daily injections of insulin (i.e., at least 3 injections per day) with frequent self-adjustments of
insulin dose for at least 6 months prior to initiation of the insulin pump, and has documented frequency of
glucose self-testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin
pump, and meets one or more of the following criteria (1 - 5) while on the multiple injection regimen:
1. Glycosylated hemoglobin level (HbA1C) greater than 7 percent
2. History of recurring hypoglycemia
3. Wide fluctuations in blood glucose before mealtime
4. Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL
5. History of severe glycemic excursions
D. The beneficiary has been on an external insulin infusion pump prior to enrollment in Medicare and
has documented frequency of glucose self-testing an average of at least 4 times per day during the month prior
to Medicare enrollment.
You can find this in the Local Coverage Determination (LCD): External Infusion Pumps (L33794).
The rules say that Continuous Glucose Monitor (CGM) devices covered by Medicare under the DME benefit
are defined in CMS Ruling 1682R as therapeutic CGMs. You can find this in the Local Coverage
Determination (LCD): Glucose Monitors (L33822).
The rules also say Codes A9276 and A9277 describe the supplies used with a non-therapeutic CGM. Codes
A9276 and A9277 are not used to bill for supplies used with code K0554. You can find this in the Local
Coverage Article: Glucose Monitor - Policy Article (A52464).
The rules say that code A4232 is invalid for submission to Medicare and should not be used for this purpose.
The rules also say that codes A4230 (infusion set for external insulin pump, non-needle cannulas type) and
A4231 (infusion set for external insulin pump, needle type) are not valid for claim submission to the DME
MAC because they are included in code A4224.
You can find this in the Local Coverage Article: External Infusion Pumps - Policy Article (A52507).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.