Guideline/Procedure Number: MPUG3025 (previously UG100325) / Lead Department: Health Services
Guideline/Procedure Title: Insulin Infusion Pump Guidelines / ☒External Policy
☐Internal Policy
Original Date: 04/19/1996 / Next Review Date: 10/18/2018
Last Review Date: 10/18/2017
Applies to: / ☒ Medi-Cal / ☐ Employees
Guideline/Procedure Number: MPUG3025 (previously UG100325) / Lead Department: Health Services
Guideline/Procedure Title: Insulin Infusion Pump Guidelines / External Policy
Internal Policy
Original Date: 04/19/1996 / Next Review Date:10/18/2018
Last Review Date:10/18/2017
Applies to: / Medi-Cal / Employees
Reviewing Entities: / IQI / P & T / QUAC
OPerations / Executive / Compliance / Department
Approving Entities: / BOARD / COMPLIANCE / FINANCE / PAC
CEO / COO / Credentialing / DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA / Approval Date:10/18/2017
  1. RELATED POLICIES:
  2. MCUP3041 - TAR Review Process
  3. MCUG3007 - Authorization of Ambulatory Procedures and Services
  4. MCUP3042 - Technology Assessment
  1. IMPACTED DEPTS:
  2. Health Services
  3. Claims
  4. Member Services
  1. DEFINITIONS:An insulin pump, also known as subcutaneous insulin infusion (CSII), is an external ambulatory infusion device used for managing insulin-requiring Diabetes Mellitus (DM). By continuous administration of short acting insulin at preselected rate, the insulin pump can improve the patient glycemic control and delay, prevent, or reduce his/her risk of complications (e.g. neuropathy, nephropathy, retinopathy).
  1. ATTACHMENTS:
  2. N/A
  1. PURPOSE:
  1. GUIDELINE / PROCEDURE:
  2. The insulin infusion pump must be ordered by the Primary Care Provider (PCP) or a specialist treating the member through a referral from the PCP. For special members, the insulin infusion pump must be ordered by the physician who is currently managing the medical care for the member.
  3. Continuous glucose monitoring will be reviewed on a case by case basis for medical necessity.
  4. Partnership HealthPlan of California (PHC) utilizes InterQual criteria to determine the necessity of apump.
  5. The TAR for insulin infusion pumps must include documentation of the medical necessity for home use of the insulin infusion pump that includes the following information related to the condition:
  6. Length of time member has had diabetes.
  7. Documentation that the member's diabetes meets InterQualcriteria for insulin pump use.
  8. Insulin infusion pumps should only be prescribed and used by practitioners familiar with this operation.
  9. Continuous Glucose Monitoring (CGM) using a non-implanted device by a healthcare provider is proven and considered medically necessary in the following clinical scenarios:
  10. Short-term (3-7 days) of continuous glucose monitoring by a healthcare provider for diagnostic purposes is proven and medically necessary for patients with diabetes. Current Procedural Terminology (CPT) codes used for this service are 95250 and 95251. Provider must be an endocrinologist or certified diabetes educator to be paid for this service. Limit one of each code per dates of service in a single calendar month. No TAR is required.
  11. Long-term continuous glucose monitoring for personal use at home is proven and medically necessary as a supplement to self-monitoring of blood glucose (SMBG) for patients with type1diabetes who have demonstrated adherence to a physician ordered diabetic treatment plan.
  12. CGM would serve as an adjunct to finger stick testing of blood glucose in adults aged 25 years and older with type 1 diabetes, despite appropriate modifications in insulin regimen and compliance with frequent self-monitoring (at least 4 finger sticks/day).
  13. CGM would serve as an adjunct for younger persons with type 1diabetes who have had recurrent episodes of severe hypoglycemia (defined as two or more episodes of hypoglycemia [blood glucose less than 50mg/dL] in a 30-day period with unawareness), despite appropriate modifications in insulin regimen and compliance with frequent self-monitoring (at least 4 finger sticks/day).
  14. Long-term continuous glucose monitoring for patients with type 2 diabetes are reviewed on a case by case basis for medical necessity. CGM for patients with type 2 diabetes may be indicated for patients with:
  15. Recurrent severe hypoglycemic unawareness in a patient taking insulin or
  16. Frequent nocturnal hypoglycemia despite modifications to insulin treatment and compliance with frequent glucose self-monitoring (at least four times a day).
  17. Long term CGM is considered experimental and investigational for nesidioblastosis (primary islet cell hypertrophy) and for monitoring blood glucose in nondiabetic persons following gastric bypass surgery.
  18. CGM using an implantable glucose sensor is investigational, unproven and not medically necessary due to lack of U.S. Food and Drug Administration (FDA) approval.
  1. REFERENCES:
  2. InterQualDME criteria – Insulin Pump, Ambulatory
  3. McCulloch DK. Blood glucose self‐monitoring in management of adults with diabetes mellitus. UpToDate Inc., Waltham, MA.
  4. Blue Cross Blue Shield Association (BCBSA), TechnologyEvaluation Center (TEC). Artificial pancreas device systems.TEC Assessment Program. Chicago, IL: BCBSA; May2014;28(14).
  5. Medtronic, Inc. MiniMed 530G system. Summary of Safetyand Effectiveness Data. Premarket Approval Application No.P120010. Rockville, MD: U.S. Food and Drug Administration; September 26, 2013. Available at:
  6. Meade LT. The use of continuous glucose monitoring inpatients with type 2 diabetes. Diabetes TechnolTher.2012;14(2):190‐195.
  1. DISTRIBUTION:
  2. PHC Departmental Directors
  3. PHC Provider Manual
  1. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:Senior Director, Health Services
  1. REVISION DATES:

Medi-Cal

04/28/00; 06/20/01; 09/18/02; 09/15/04; 11/16/05; 08/20/08; 10/01/10; 05/16/12; 04/15/15; 03/16/16; 04/19/17; 10/18/17

PREVIOUSLY APPLIED TO:

Healthy Kids MPUG3025 (Healthy Kids program ended 12/01/2016)

08/20/08; 10/01/10; 05/16/12; 04/15/15; 03/16/16 to 12/01/2016

Healthy Families

MPUG3025 - 10/01/10 to 03/01/2014

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Inaccordance with theCalifornia Healthand SafetyCode,Section 1363.5,this policywasdevelopedwith involvement from activelypracticinghealth care providersandmeetstheseprovisions:

  • Consistentwith sound clinicalprinciplesand processes
  • Evaluatedand updated atleast annually
  • Ifusedas thebasis ofadecision to modify, delayordenyservices ina specific case, thecriteria will be disclosedto the provider and/orenrollee upon request

The materials provided areguidelinesusedbyPHC to authorize, modifyor denyservices forpersonswithsimilar illnesses or conditions.Specific care andtreatment mayvarydependingonindividualneedand the benefitscovered underPHC.

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