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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 say that the following indications for treatment using infusion pumps are covered under Medicare: 
1. External Infusion Pumps 
a.     Iron Poisoning (Effective for Services Performed On or After September 26, 1984) 
When used in the administration of deferoxamine for the treatment of acute iron poisoning and iron overload, 
only external infusion pumps are covered. 
b.     Thromboembolic Disease (Effective for Services Performed On or After September 26, 1984) 
When used in the administration of heparin for the treatment of thromboembolic disease and/or pulmonary 
embolism, only external infusion pumps used in an institutional setting are covered. 
c.     Chemotherapy for Liver Cancer (Effective for Services Performed On or After January 29, 1985) 
The external chemotherapy infusion pump is covered when used in the treatment of primary hepatocellular 
carcinoma or colorectal cancer where this disease is unresectable; OR, where the patient refuses surgical 
excision of the tumor. 
d.     Morphine for Intractable Cancer Pain (Effective for Services Performed On or After April 22, 1985) 
Morphine infusion via an external infusion pump is covered when used in the treatment of intractable pain 
caused by cancer (in either an inpatient or outpatient setting, including a hospice). 
e.     Continuous Subcutaneous Insulin Infusion (CSII) Pumps (Effective for Services Performed On or after 
December 17, 2004) 
Continuous subcutaneous insulin infusion (CSII) and related drugs/supplies are covered as medically 
reasonable and necessary in the home setting for the treatment of diabetic patients who: (1) either meet the 
updated fasting C-Peptide testing requirement, or, are beta cell autoantibody positive; and, (2) satisfy the 
remaining criteria for insulin pump therapy as described below. Patients must meet either Criterion A or B as 
follows: 
Criterion A: The patient has completed a comprehensive diabetes education program, and has been on a 
program of multiple daily injections of insulin (i.e., at least three injections per day), with frequent self-
adjustments of insulin doses for at least six months prior to initiation of the insulin pump, and has documented 
frequency of glucose self-testing an average of at least four times per day during the two months prior to 
initiation of the insulin pump, and meets one or more of the following criteria while on the multiple daily 
injection regimen: 
- Glycosylated hemoglobin level (HbAlc) greater than 7.0%; 
- History of recurring hypoglycemia; 
- Wide fluctuations in blood glucose before mealtime; 
- Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or, 
- History of severe glycemic excursions. 
Criterion B: The patient with diabetes has been on a pump prior to enrollment in Medicare and has documented 
frequency of glucose self-testing an average of at least four times per day during the month prior to Medicare 
enrollment. 
General CSII Criteria 
In addition to meeting Criterion A or B above, the following general requirements must be met: 
The patient with diabetes must be insulinopenic per the updated fasting C-peptide testing requirement, or, as an 
alternative, must be beta cell autoantibody positive. 
Updated fasting C-peptide testing requirement: 
- Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110% of the lower 
limit of normal of the laboratory's measurement method. 
- For patients with renal insufficiency and creatinine clearance (actual or calculated from age, 
gender, weight, and serum creatinine) less than or equal to 50 ml/minute, insulinopenia is defined 
as a fasting C-peptide level that is less than or equal to 200% of the lower limit of normal of the 
laboratory's measurement method. 
- Fasting C-peptide levels will only be considered valid with a concurrently obtained fasting 
glucose less than or equal to 225 mg/dL. 
- Levels only need to be documented once in the medical records. 
Continued coverage of the insulin pump would require that the patient be seen and evaluated by the treating 
physician at least every three months. 
The pump must be ordered by and follow-up care of the patient must be managed by a physician who manages 
multiple patients with CSII and who works closely with a team including nurses, diabetes educators, and 
dietitians who are knowledgeable in the use of CSII. 
You can find this rule in the National Coverage Determination Manual Chapter 1, Section 280.14. 
 
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.