K0455, Infusion pump used for uninterrupted parenteral administration of medication,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before claim submission and a signed Written Order Prior to Delivery (WOPD) must be received before delivery of DMEPOS base items that require WOPD.
- Proof of delivery (POD) documentation must be maintained by the supplier and be made available to the Medicare contractor upon request; claims without appropriate POD will be denied.
- For insulin pump coverage, document C-peptide testing (meeting specified thresholds), beta cell autoantibody positivity, comprehensive diabetes education completion, prior multiple daily injection regimen (≥3 injections/day for ≥6 months) with self-adjustments, and documented glucose self-testing frequency (average ≥4 times/day for 2 months prior to initiation or ≥4 times/day during the month prior to Medicare enrollment if previously on a pump).
Key Coverage Criteria
- 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).
- External ambulatory insulin infusion pumps that incorporate non-adjunctive CGM dose adjustment are described by HCPCS combination E0784 + E2103 and are covered only if the beneficiary meets all insulin pump criteria and all CGM criteria in Glucose Monitors LCD L33822.
- External ambulatory insulin infusion pumps with integrated adjunctive CGM receiver functionality are described by HCPCS combination E0784 + E2102 and are covered only if the beneficiary meets all insulin pump criteria and all CGM criteria in Glucose Monitors LCD L33822 (claims on/after 4/1/2022).
2 Active Policies
L33794, External Infusion Pumps
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
Related Codes
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