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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 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. 
 
An IV pole (E0776) is covered only when a stationary infusion pump (E0791) is covered. It is considered not 
reasonable and necessary if it is billed with an ambulatory infusion pump (E0779, E0780, E0781, E0784, or 
K0455). 
 
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. 
 
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.