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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 say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
The rules say 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). 
I. Administration of deferoxamine for the treatment of chronic iron overload. 
II. 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. 
III. Administration of morphine when used in the treatment of intractable pain caused by cancer. 
IV. 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:  
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. You can find the 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.