Anthem Blue Cross Connecticut CG-DME-21 External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings Form

This document addresses the use of external infusion pumps for the administration of parenteral or enteral drugs in the home or other residential care settings for diagnoses other than diabetes mellitus or pulmonary hypertension. The administration of oral or enteral nutrition is not addressed in this document.

Note: Please see the following documents for further information regarding other types or uses for infusion pumps:

• CG-DME-09 Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump during the Post-Operative Period
• CG-DME-50 Automated Insulin Delivery Systems
• CG-DME-51 External Insulin Pumps
• CG-DME-42 Continuous Glucose Monitoring Devices
• CG-MED-23 Home Health

Note: Please see the following document for information regarding the administration of oral or enteral nutrition:

• CG-MED-08 Home Enteral Nutrition

Clinical Indications

Medically Necessary:

An external infusion pump is considered medically necessary for the administration of intravenous medications if either of the following sets of criteria (Criteria set 1 OR Criteria set 2) is met:

Criteria set 1

• Parenteral administration of the drug in the home is reasonable and necessary; and
• An infusion pump is necessary to safely administer the drug; and
• The drug is administered by a prolonged infusion of at least 8 hours because of proven improved clinical efficacy; and

The therapeutic regimen is proven or generally accepted to have significant advantages over intermittent bolus administration regimens or infusions lasting less than 8 hours.

Criteria set 2

• Parenteral administration of the drug in the home is reasonable and necessary; and
• An infusion pump is necessary to safely administer the drug; and
• The drug is administered by intermittent infusion (each episode of infusion lasting less than 8 hours) that does not require the individual to return to the physician’s office prior to the beginning of each infusion; and
• Systemic toxicity or adverse effects of the drug are unavoidable without infusing it at a strictly controlled rate as indicated in the Prescribers’ Digital Reference.

An external infusion pump is considered medically necessary for the administration of enteral medications when all of the following criteria have been met:

• The infusion pump is necessary to safely administer the drug; and
• The drug is administered in a time and rate limited infusion in accordance with its U.S. Food & Drug Administration (FDA) prescribing information label.

Not Medically Necessary:

External infusion pumps and related supplies are considered not medically necessary when the criteria described above are not met.

An external infusion pump is considered not medically necessary for the administration of enteral medications when the criteria above have not been met.