CG-DME-21 External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings

This policy addresses external infusion pumps (ambulatory, stationary, or reusable mechanical) used to deliver parenteral (intravenous) drugs in the home or residential care setting. Coverage is medically necessary when home parenteral therapy is reasonable and necessary, a pump is required for safe administration, the drug requires a prolonged infusion of at least 8 hours due to improved efficacy, and the regimen has proven or generally accepted advantages over bolus or shorter infusions. Pumps and related supplies are not covered when these criteria are not met, including for enteral medication administration.

"An external infusion pump is consideredmedically necessaryfor the administration ofintravenousmedications ifeitherof the following sets of criteria (Criteria set 1 OR Criteria set 2) is met:"

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