Insulin External Infusion pump & Supplies
Medicare Coverage Criteria for Insulin Pump and Supplies
infusion pump is covered for continuous subcutaneous insulin for the treatment of diabetes mellitus 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:
- 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 laboratory’s 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.
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:
- 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
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.
When an infusion pump is covered, the necessary supplies are also covered. When a pump has been purchased by the Medicare program, other insurer, the beneficiary, or the rental cap has been reached, the drug necessitating the use of the pump and supplies are covered as long as the coverage criteria for the pump are met.
