A4223 — Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A Standard Written Order (SWO) must be received by the supplier before claim submission for items requiring a SWO; for DMEPOS base items a signed WOPD is required prior to delivery.
- Suppliers must maintain and produce proof of delivery (POD) documentation upon request by the Medicare contractor.
- For DMEPOS refills, suppliers must document an affirmative response from the beneficiary or designee prior to dispensing refills and must not automatically ship pre-determined refills.
- Suppliers must verify and document that dispensed quantities reflect expected utilization and must consult treating practitioners if utilization is changed or atypical.
Key Coverage Criteria
- IVIG is covered when the product is eligible under a Medicare benefit category, is reasonable and necessary for diagnosis or treatment per Social Security Act §1862(a)(1)(A), and meets all other applicable Medicare statutory and regulatory requirements and related LCD/Policy Article rules.
- IVIG may be covered only when dispensed and billed to Medicare by the same entity that actually dispenses the drug to the Medicare beneficiary and that entity is licensed to dispense drugs in the state where it is physically located.
- External infusion pumps (HCPCS E0779, E0780, E0781, E0791) are covered for administration of deferoxamine for treatment of chronic iron overload.
- External infusion pumps are covered for administration of anticancer chemotherapy for unresectable primary hepatocellular carcinoma or unresectable colorectal cancer or when the beneficiary refuses surgical excision of the tumor.
- External infusion pumps are covered for administration of morphine for intractable cancer pain.
- Continuous subcutaneous insulin infusion (pump E0784) is covered for diabetes mellitus when the beneficiary meets either criterion A (C-peptide/autoantibody evidence of insulin deficiency) or B (prior successful insulin pump use before Medicare enrollment) and either criterion C (prior multiple daily injection program with documented deficiencies) or D (prior pump use with documented glucose testing).
3 Active Policies
L33610 — Intravenous Immune Globulin
J19
L33794 — External Infusion Pumps
J19
L40247 — External Infusion Pumps
J19
Related Codes
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