Appeal type: unknown
Decision: unknown

 
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 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 laboratorys 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. 
 
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. You can find these rules in 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.