OAR 410-122-0525
External Insulin Infusion Pump


(1)

Indications and limitations of coverage and medical appropriateness:

(a)

The Division may cover an external insulin infusion pump for the administration of continuous subcutaneous insulin for the treatment of diabetes mellitus when criterion (A) or (B) is met and criterion (C) or (D) is met:

(A)

C-peptide testing requirement:
(i)
The C-peptide level is less than or equal to 110 percent of the lower limit of normal of the laboratory’s measurement method; or
(ii)
For a client 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 laboratory’s measurement method; and
(iii)
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 client has:
(i)
Completed a comprehensive diabetes education program; and
(ii)
Been on a program of multiple daily injections of insulin (i.e., at least three injections per day) with frequent self-adjustments of insulin dose for at least six months prior to initiation of the insulin pump; and
(iii)
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 injection regimen:

(I)

Glycosylated hemoglobin level (HbA1C) greater than 7 percent;

(II)

History of recurring hypoglycemia;

(III)

Wide fluctuations in blood glucose before mealtime;

(IV)

Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL;

(V)

History of severe glycemic excursions;

(D)

The client has:
(i)
Been on an external insulin infusion pump prior to enrollment in the medical assistance program, and;
(ii)
Documented frequency of glucose self-testing an average of at least four times per day during the month prior to medical assistance program enrollment;

(b)

For continued coverage of an external insulin pump and supplies, the client shall be seen and evaluated by the treating physician at least every three months;

(c)

The external insulin infusion pump shall be ordered and follow-up care rendered by a physician who manages multiple clients 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;

(d)

The Division may cover supplies (including dressings) used with an external insulin infusion pump during the period of covered use of an infusion pump. These supplies are billed with codes A4221 and K0552;

(e)

Code A4221 includes catheter insertion devices for use with external insulin infusion pump infusion cannulas and are not separately payable;

(f)

A4221 is limited to one unit of service per week.

(2)

Coding guidelines:

(a)

Code A4221 includes all cannulas, needles, dressings, and infusion supplies (excluding the insulin reservoir) related to continuous subcutaneous insulin infusion via external insulin infusion pump (E0784);

(b)

Code K0552 describes a syringe-type reservoir that is used with the external insulin infusion pump (E0784).

(3)

Documentation requirements:

(a)

With the request for PA, the DMEPOS provider shall submit medical justification that supports the criteria in this rule are met;

(b)

When billing and dispensing for an item in Table 122-0525, the DMEPOS provider shall ensure that medical records corroborate all criteria in this rule are met;

(c)

The DMEPOS provider shall keep medical records on file and make them available to the Division upon request.

(4)

Table 122-0525.
[ED. NOTE: Tables referenced are available from the agency.]
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

Source: Rule 410-122-0525 — External Insulin Infusion Pump, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-122-0525.

410‑122‑0010
Definitions
410‑122‑0020
Orders
410‑122‑0040
Prior Authorization
410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions
410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients)
410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding
410‑122‑0182
Legend
410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing
410‑122‑0186
Payment Methodology
410‑122‑0188
DMEPOS Rebate Agreements
410‑122‑0200
Pulse Oximeter for Home Use
410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea
410‑122‑0203
Oxygen and Oxygen Equipment
410‑122‑0204
Nebulizer
410‑122‑0205
Respiratory Assist Devices
410‑122‑0206
Intermittent Positive Pressure Breathing
410‑122‑0207
Respiratory Supplies
410‑122‑0208
Suction Pumps
410‑122‑0209
Tracheostomy Care Supplies
410‑122‑0210
Ventilators
410‑122‑0211
Cough Stimulating Device
410‑122‑0220
Pacemaker Monitor
410‑122‑0240
Apnea Monitors for Infants
410‑122‑0250
Breast Pumps
410‑122‑0260
Home Uterine Monitoring
410‑122‑0280
Heating/Cooling Accessories
410‑122‑0300
Light Therapy
410‑122‑0320
Manual Wheelchair Base
410‑122‑0325
Power Wheelchair Base
410‑122‑0330
Power-Operated Vehicle
410‑122‑0340
Wheelchair Options/Accessories
410‑122‑0360
Canes and Crutches
410‑122‑0365
Standing and Positioning Aids
410‑122‑0375
Walkers
410‑122‑0380
Hospital Beds
410‑122‑0400
Pressure Reducing Support Surfaces
410‑122‑0420
Hospital Bed Accessories
410‑122‑0475
Therapeutic Shoes for Diabetics
410‑122‑0510
Osteogenesis Stimulator
410‑122‑0515
Neuromuscular Electrical Stimulator (NMES)
410‑122‑0520
Glucose Monitors and Diabetic Supplies
410‑122‑0525
External Insulin Infusion Pump
410‑122‑0540
Ostomy Supplies
410‑122‑0560
Urological Supplies
410‑122‑0580
Bath Supplies
410‑122‑0590
Patient Lifts
410‑122‑0600
Toilet Supplies
410‑122‑0620
Miscellaneous Supplies
410‑122‑0625
Surgical Dressing
410‑122‑0630
Incontinent Supplies
410‑122‑0640
Eye Prostheses
410‑122‑0655
External Breast Prostheses
410‑122‑0658
Gradient Compression Stockings/Sleeves
410‑122‑0660
Orthotics and Prosthetics
410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses
410‑122‑0678
Dynamic Adjustable Extension/Flexion Device
410‑122‑0680
Facial Prostheses
410‑122‑0700
Negative Pressure Wound Therapy Pumps
410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0525’s source at or​.us