TMPPM 2008 > Texas Medicaid Services > Texas Medicaid (Title XIX) Home Health Services > Benefits

24.5.12.4 Insulin Pump

The following procedure codes for the external insulin pumps and associated supplies are a benefit of the Texas Medicaid Program and may be considered through Home Health Services. Note that a replacement leg bag may be requested with procedure code 9-A9900. The initial leg bag is part of the purchase of the pump.

Insulin Pump Procedure Codes and Limitations

Prior authorization is required for external insulin pumps (J/L-E0784) with carrying cases and their related supplies. The external insulin pump supplies may be reimbursed separately in addition to the external insulin pump rental.

The following information, which must be documented on the External Insulin Infusion Pump form, is the minimum documentation required for consideration of medical necessity:

•Lab values, current and past blood glucose levels, including glycosylated hemoglobin (Hb/A1C) levels.

•History of severe glycemic excursions, brittle diabetes, hypoglycemic/hyperglycemic reactions, nocturnal hypoglycemia, any extreme insulin sensitivity and/or very low insulin requirements.

•Any wide fluctuations in blood glucose before mealtimes.

•Any Dawn phenomenon where fasting blood glucose level often exceeds 200 mg/dL.

•Day-to-day variations in work schedule, mealtimes and/or activity level, which require multiple insulin injections.

•Completed, signed, and dated Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form.

The external insulin pump may be considered for purchase after it has been rented for three months and the physician provides documentation that it is the appropriate equipment for the client and the client is compliant with use. This documentation and a newly completed Home Health Services form and new External Insulin Infusion Pump form must be submitted to TMHP Home Health Services Prior Authorization Department for prior authorization.

An internal insulin pump will not be prior authorized, because reimbursement for the pump is included in the reimbursement for the surgery to place the insulin pump.

A determination will be made by the prior authorization nurse as to whether the equipment will be rented, purchased, repaired, or modified based on the client's needs, duration of use, and the age of the equipment.

To avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the equipment and/or supplies requested. The physician must maintain documentation of medical necessity in the client's medical record. The requesting provider may be asked for additional information to clarify or complete a request for the diabetic equipment or supplies.