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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 the following indications (I-V): 
 
An infusion pump described by codes E0779, E0780, E0781, and E0791 is covered for indications I  III, V(A) 
 V(D), V(F), V(G), V(I) and V(J). Coverage of other pumps is addressed under indications IV, V (E), and V 
(H). 
 
    Administration of deferoxamine for the treatment of chronic iron overload. 
    Administration of chemotherapy for the treatment of primary hepatocellular carcinoma or colorectal cancer 
where this disease is unresectable or where the beneficiary refuses surgical excision of the tumor. Anticancer 
chemotherapy drugs used in these conditions are not required to meet the criteria described by indication V, 
situation A. 
    Administration of morphine when used in the treatment of intractable pain caused by cancer. 
    Administration of continuous subcutaneous insulin for the treatment of diabetes mellitus (Refer to the ICD-
10 code list in the LCD-related Policy Article for applicable diagnoses.) if criterion A or B is met and if 
criterion C or D is met: 
        C-peptide testing requirement  must meet criterion 1 or 2 and criterion 3: 
            C-peptide level is less than or equal to 110 percent of the lower limit of normal of the laboratory's 
measurement method. 
            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 laboratorys measurement method. 
            A fasting blood sugar obtained at the same time as the C-peptide level is less than or equal to 225 
mg/dl. 
        Beta cell autoantibody test is positive. 
        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: 
            Glycosylated hemoglobin level (HbA1C) greater than 7 percent 
            History of recurring hypoglycemia 
            Wide fluctuations in blood glucose before mealtime 
            Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL             History of severe glycemic excursions 
        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. 
 
    If criterion A or B is not met, the pump and related accessories, supplies, and insulin will be denied as not 
reasonable and necessary. If criterion C or D is not met, the pump and related accessories, supplies, and insulin 
will be denied as not reasonable and necessary. 
 
    Continued coverage of an external insulin pump and supplies requires that the beneficiary be seen and 
evaluated by the treating practitioner at least every 3 months. In addition, the external insulin infusion pump 
must be ordered and follow-up care rendered by a practitioner who manages multiple beneficiaries on 
continuous subcutaneous insulin infusion therapy and who works closely with a team including nurses, diabetic 
educators, and dieticians who are knowledgeable in the use of continuous subcutaneous insulin infusion 
therapy. 
 
    Subcutaneous insulin is administered using ambulatory infusion pump E0784. Claims for usage of infusion 
pumps other than E0784 will be denied as not reasonable and necessary. 
 
    For the external ambulatory insulin infusion pumps that incorporate dose rate adjustment via continuous 
glucose monitors (CGMs), the term CGM refers to both therapeutic/non-adjunctive and non-
therapeutic/adjunctive CGMs. For the purpose of this LCD, the term therapeutic may be used 
interchangeably with the term non-adjunctive. Likewise, the term non-therapeutic may be used 
interchangeably with the term adjunctive. 
 
    The HCPCS code combination of E0784 plus K0554 is used to describe external ambulatory insulin infusion 
pumps that incorporate dose rate adjustment using non-adjunctive continuous glucose sensing. Coverage for 
this HCPCS code combination is only met if the beneficiary meets all of the coverage criteria for insulin pumps 
outlined in this policy and all criteria for CGMs as outlined in the Glucose Monitors LCD (L33822). 
 
    For claims with dates of service on or after April 1, 2022, the HCPCS code combination of E0784 plus 
E2102 is used to describe external ambulatory insulin infusion pumps with integrated adjunctive continuous 
glucose monitor receiver functionality. Coverage for this HCPCS code combination is only met if the 
beneficiary meets all of the coverage criteria for insulin pumps outlined in this policy and all criteria for CGMs 
as outlined in the Glucose Monitors LCD (L33822). 
 
    Refer to the GENERAL section below, and to the CODING GUIDELINES section in the LCD-related 
Policy Article for additional information regarding supplies used in conjunction with insulin infusion pumps 
(E0784). 
 
    Claims with dates of service on or after January 01, 2017 for supply HCPCS codes A4221, A4222 and 
K0552, when used with an external infusion pump HCPCS code E0784 will be denied as incorrect coding. 
 
    Administration of other drugs if either of the following sets of criteria (1) or (2) are met: 
        Criteria set 1: 
            Parenteral administration of the drug in the home is reasonable and necessary 
            An infusion pump is necessary to safely administer the drug 
            The drug is administered by a prolonged infusion of at least 8 hours because of proven improved 
clinical efficacy 
            The therapeutic regimen is proven or generally accepted to have significant advantages over 
intermittent bolus administration regimens or infusions lasting less than 8 hours 
        Criteria set 2:              Parenteral administration of the drug in the home is reasonable and necessary 
            An infusion pump is necessary to safely administer the drug 
            The drug is administered by intermittent infusion (each episode of infusion lasting less than 8 hours) 
which does not require the beneficiary to return to the practitioner's office prior to the beginning of each 
infusion 
            Systemic toxicity or adverse effects of the drug are unavoidable without infusing it at a strictly 
controlled rate as indicated in the Physicians Desk Reference, or the U.S. Pharmacopeia Drug Information 
 
You can find this information in the Local Coverage Determination (LCD) External Infusion Pumps L33794. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.