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