MEDICARE COVERAGE CRITERIA FOR INFUSION THERAPY - UW …

MEDICARE COVERAGE CRITERIA FOR INFUSION THERAPY

ITEM

Antibiotics

MEDICARE COVERAGE CRITERIA

An infusion pump is necessary to safely administer the drug and: 1. The drug is administered by a prolonged infusion of at least 8 hours. 2. The therapeutic regimen is proven or generally accepted to have significant advantages over intermittent bolus administration regimens or

infusions lasting less than 8 hours. or 1. The drug is administered by intermittent infusion (each episode less than 8 hours) and does not require the patient to return to the physician

prior to the next infusion. 2. Systemic toxicity or adverse effects of the drug is unavoidable without infusing it at a strictly controlled rate.

Covered drugs are: Acyclovir, Amphotericin B, Foscarnet, and Ganciclovir. Liposomal amphotericin B (J0287-J0289) is covered for patients who have suffered some significant toxicity that would preclude the use of standard amphotericin B, or patients having significantly impaired renal function.

Catheter Care

Administered between covered IV therapies up to 4 weeks per episode.

Chemotherapy

Administered by an external infusion pump. Any drug is covered if the diagnosis is hepatocellular carcinoma or colorectal cancer where the disease is unresectable or the patient refuses surgery. Other diagnoses covered when one of the following drugs is used and administered over at least 8 hours: Bleomycin Sulfate (Blenoxane), Cladribine, Cytarabine (Cytosar-U), Doxorubicin HCL (Adriamycin PFS. Adriamycin RDF, Rubex), Fluorouracil (Adrucil), Floxuridine (FUDR), Vinblastine Sulfate (Velban, Velsar, Alkaban-AQ), Vincristine Sulfate (Oncovin, Vincasar PFS).

Desferral

Administered by an external infusion pump. Covered for treatment of chronic iron overload.

Enteral

Covered for a patient who has (a) a permanent (ordinarily, at least 3 months) nonfunction or disease of the structures that normally permit food to reach the small bowel or (b) disease of the small bowel which impairs digestion and absorption of an oral diet.

Epogen

Covered only when provided by the Method II supplier of home dialysis equipment.

Epoprostenol, Treprostinil

Covered for patients with pulmonary hypertension if they meet the following disease criteria: 1) the pulmonary hypertension is not secondary to pulmonary venous hypertension or disorders of the respiratory system such as, COPD, interstitial lung disease, OSA, etc., 2) the patient has primary pulmonary Hypertension or pulmonary hypertension which is secondary to one of the following conditions: connective tissue disease, thromboembolic disease of the pulmonary arteries, HIV infection, cirrhosis, diet drugs, congenital left to right shunts, etc. if specific conditions are met.

Gallium Nitrate

Covered for the treatment of symptomatic cancer-related hypercalcemia (ICD-9 275.42). In general, patients with a serum calcium (corrected for albumin) less than 12 mg/dl would not be expected to be symptomatic. The recommended usage for gallium nitrate is daily for five consecutive days.

Hydration

Not covered.

MEDICARE COVERAGE CRITERIA FOR INFUSION THERAPY

ITEM

Inotropic Drugs Dobutamine, Milrinone, Dopamine

Insulin

Pain Management

TPN

MEDICARE COVERAGE CRITERIA

Administered by an external infusion pump. Diagnosis of congestive heart failure and depressed cardiac function and 1) dyspnea at rest despite documented treatment, 2) doses are within specific ranges, 3) invasive hemodynamic studies performed within 6 months prior to start of home therapy show a) cardiac index (CI) is less than or equal to 2.2 liters/min/meter squared and/or pulmonary capillary wedge pressure (PCWP) is greater than or equal to 20mm Hg before inotrope infusion and b) at least a 20% increase in CI and/or at least a 20% decrease in PCWP during inotropic infusion, 4) there is improvement in patient well being, 5) in the case of continuous infusion, there is documented deterioration in clinical status when the drug is tapered or discontinued, in the case of intermittent infusions, there is documentation of repeated hospitalizations for CHF, 6) any life threatening arrhythmia is controlled prior to hospital discharge and there is no need for routine ECG monitoring at home, 7) the patient is maintained on the lowest possible dose and efforts to decrease the dose or the frequency/duration are documented during the first three months of therapy, 8) the patient's cardiac symptoms, vital signs, weight, lab values , and response to therapy are routinely assessed and documented.

Administration of continuous subcutaneous insulin for the treatment of diabetes mellitus, (ICD-9 codes 250.00-250.93), which has been documented by a fasting serum C-peptide level that is less than or equal to 110 percent of the lower limit of normal of the laboratory's measurement method if specific criteria are met (See Supplier Manual).

Administered by an external infusion pump. Administration of morphine when used in the treatment of intractable pain caused by cancer. Administration of narcotic analgesics (except meperidine) in place of morphine to a patient with intractable pain caused by cancer who has not responded to or cannot tolerate oral/transdermal therapeutic regimen.

Covered for a patient with permanent (ordinarily, at least 3 months) severe pathology of the alimentary tract, which does not allow absorption of sufficient nutrients to maintain weight and strength. The patient must have a) a condition involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or b) disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through the GI system. See Supplier Manual for specifics. Additional medical documentation would be required if total daily caloric intake is outside the range of 20-35 cal/kg/day, if protein is outside the range of 0.8-1.5 gm/kg/day, dextrose concentration less than 10%, or lipid use greater than 15 units of 20% solution or 30 units of 10% solution per month.

Information gathered from various CMS web sites. Chartwell Diversified Services, Inc. 2008

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