TMPPM 2007 >24.5.21 Intravenous (IV) Therapy Equipment and Supplies

The following equipment and supplies are used in the delivery of IV therapy and are a benefit of Home Health Services. Additional supply procedure codes may be considered with documentation of medical necessity:


Procedure Code
9-A4206	9-A4207	9-A4208
9-A4209	9-A4212	9-A4222
9-A4245	9-A4247	9-A4300
9-A4305	9-A4306	9-A4450
9-A4452	9-A4930	9-A6206
9-A6207	9-A6257	9-A6258
9-A6402	9-A9900	9-S1015
J/L-E0776	J/L-E0779	J/L-E0780
J/L-E0781	J/L-E0791

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Central IV lines, including but not limited to, peripherally-inserted central catheters, subclavian catheters, and vena cava catheters.

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Central venous lines, including but not limited to, tunneled and peripherally inserted central venous catheters.

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Implantable ports, including but not limited to, access devices with subcutaneous ports.

Prior authorization of IV equipment and supplies may be considered when administration of the drug in the home is medically necessary and is appropriate in the home setting. IV equipment may be prior authorized for rental or purchase depending on the clinician's predicted length of treatment.

An IV infusion pump that has been purchased is anticipated to last a maximum of 5 years and may be considered for replacement when 5 years have passed and/or the equipment is no longer repairable. The DME may then be considered for prior authorization. Replacement of equipment may also be considered when loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent a reoccurrence must be submitted.

A completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form that prescribes the DME and/or medical supplies must be signed and dated by a prescribing physician who is familiar with the client before requesting authorization. All signatures must be current, unaltered, original, and handwritten. Computerized or stamped signatures will not be accepted. The completed, signed, and dated Home Health DME Prior Authorization Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept in the physician's medical record for the client.

To avoid unnecessary denials, the physician must provide correct and complete information, including documentation of the medical necessity of 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 IV therapy equipment and supplies.

To request prior authorization for IV supplies and equipment, the following documentation must be provided:

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The medication being administered, the duration of drug therapy, and the frequency of administration.

The following standards are used when considering prior authorization of IV supplies:

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The aseptic technique is acceptable for IV catheter insertion and site care; the sterile technique is not required:

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Non-sterile gloves are acceptable for the insertion of a peripheral IV catheter and for changing any IV site dressing.

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The sterile technique may be medically necessary. Examples of medical necessity include, but are not limited to, a client who is immuno-compromised.

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A peripheral IV site is rotated no more frequently than every 72 hours, but it is rotated at least weekly.

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The IV administration set (with or without dial flow regulator), extension set (with or without dial flow regulator), and any add-on devices are changed every 72 hours.

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Use one syringe to flush the catheter before administration of an intermittent infusion to assess.

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Use two syringes to flush the catheter after the intermittent infusion-one to clear the medication and one to infuse the anticoagulant or other medication used to maintain IV patency between doses, including, but not limited to, heparin.

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An injection port is cleaned before administering an intermittent infusion and capped after the infusion.

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Disinfect the site with an appropriate antiseptic (including but not limited to 2 percent chlorhexidine-based preparation, tincture of iodine, or 70 percent alcohol).

Stopcocks increase the risk of infection and should not be routinely used for infusion administration. Routine use of in-line filters is not recommended for infection control.

Note: Non-sterile/sterile gloves for use by a health-care provider in the home setting, such as an RN, LVN, or attendant, are not a benefit of Home Health Services.

Stationary infusion pumps are electrical devices without a battery, or with a battery that requires frequent recharging (more frequently than every 4 hours), used to deliver an intravenous solution or parenteral drugs at a steady flow rate. Stationary infusion pumps may be a benefit when the infusion rate must be more consistent and cannot be obtained with gravity drainage.

Ambulatory infusion pumps are electrical devices that have an extended battery life (four hours or longer without recharging) used to deliver an intravenous solution or parenteral drugs at a steady flow rate. Ambulatory infusion pumps may be a benefit when the length of infusion is greater than two hours, the client must be involved in activities away from home, and when the infusion rate must be more consistent and cannot be obtained with gravity drainage.

Elastomeric infusion pumps are non-electrical, single use, simplified devices that deliver parenteral drugs at a fixed volume and flow rate. Elastomeric infusion pumps may be a benefit for short-term use when the caregiver cannot administer the infusion via pump. Dial flow regulators, such as dial-a-flow, are incorporated into IV extension sets or IV tubing. They are non-electrical, single use, simplified devices that deliver parenteral drugs at a fixed volume and flow rate utilizing a dial system to set a flow rate.

If additional supplies are needed beyond the standards listed in this policy, prior authorization may be considered with documentation supporting medical necessity.

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For additional IV access catheters, supporting documentation should have evidence that includes, but is not limited to:

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Fragile veins, including but not limited to, clients who are infants or elderly.

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For more frequent IV site changes, supporting documentation should have evidence that includes, but is not limited to:

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For more frequent IV tubing or add-on changes, supporting documentation should have evidence that includes, but is not limited to:

Elastomeric devices and dial flow regulators are specialized infusion devices that may be considered for prior authorization when the device:

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Will be used for short-term medication administration (less than two weeks duration)

Elastomeric devices may be reimbursed using procedure codes 9-A4305 and 9-A4306.

The following criteria must be met for prior authorization of a stationary infusion pump:

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The standard method of administration of the drug is through prolonged infusion or intermittent infusion, and the infusion rate must be more consistent than can be obtained with gravity drainage.

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The drug being administered requires IV infusion (i.e., the drug cannot be administered orally, intramuscularly, or by push technique).

The following criteria must be met for prior authorization of an ambulatory infusion pump:

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The standard method of administration of the drug is through prolonged infusion or intermittent infusion and the infusion rate must be more consistent than can be obtained with gravity drainage.

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The drug being administered requires IV infusion (i.e., the drug cannot be administered orally, intramuscularly, or via push technique).

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The infusion administration is more than two hours and the client is involved in activities away from home, including, but not limited to, physician visits.

Rental of an infusion pump may be prior authorized on a monthly basis for a maximum of four months per lifetime. Purchase of an infusion pump (ambulatory or stationary) may be prior authorized with documentation of medical necessity that supports repeated IV administration for a chronic condition.

For clients who require cardiovascular medications, infusion pumps will be rented, but not purchased.

Repairs to client-owned equipment may be prior authorized as needed with documentation of medical necessity. Technician fees are considered part of the cost of the repair. Providers are responsible for maintaining documentation in the client's medical record that specifies the repairs and supports medical necessity.

All repairs within the first six months after delivery are considered part of the purchase price. Additional documentation, such as the purchase date, serial number, and manufacturer's information, may be required.

IV therapy, supplies, and equipment are not considered a benefit when the infusion/medication being administered:

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Is not considered medically necessary to the treatment of the client's illness.

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Is not FDA-approved, unless the physician documents why the off-label use is medically appropriate and not likely to result in an adverse reaction. In order to consider coverage of an off-label (non-FDA approved) use of a drug, documentation must include why a drug usually indicated for the specific diagnosis or condition has not been effective for the client.

In situations where the equipment has been abused or neglected by the client, the client's family, or the caregiver, a referral to the DSHS THSteps Case Management Department will be made by the Home Health Services Prior Authorization Department for clients under 21 years of age. Providers will be notified that the state will be monitoring the client's services to evaluate the safety of the environment for both the client and the equipment.

The completed, signed, and dated DME Certification and Receipt Form is required before reimbursement can be made for any DME delivered to a client. The certification form must include the name of the item, the date the client received the DME, and the signatures of the provider and the client or primary caregiver. This form must be maintained by the DME provider in the client's medical record.