Aetna · Clinical coverage policy

Aetna Infusion Pumps coverage criteria

Aetna CPB 0161 covers infusion pumps as medically necessary only for specific drug-and-condition pairings: implantable pumps for intrathecal baclofen in severe spasticity, intrathecal/epidural opioids (morphine), ziconotide or clonidine for severe chronic intractable pain after a successful trial, and intrahepatic floxuridine chemotherapy for primary liver cancer or colorectal-only liver metastases; external pumps for listed chemotherapy, antifungals/antivirals, deferoxamine, heparin, insulin (with detailed diabetes selection criteria), cancer-pain narcotics, pulmonary-hypertension and inotropic agents, and post-op nerve blocks. The core gate in each case is that the drug requires pump-controlled delivery, the device is FDA-approved for that drug, and (for trials/implants) a documented favorable response is shown; uses outside the listed indications (e.g., subacromial pain pumps, intrathecal baclofen for cancer/neuropathic pain, implantable insulin pumps) are excluded as experimental/investigational or not medically necessary.

Policy CPB 0161 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0161

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0161 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Infusion Pumps (CPT 62360), and what gets it denied?

Path
Aetna CPB 0161 covers infusion pumps as medically necessary only for specific drug-and-condition pairings: implantable pumps for intrathecal baclofen in severe spasticity, intrathecal/epidural opioids (morphine), ziconotide or clonidine for severe chronic intractable pain after a successful trial, and intrahepatic floxuridine chemotherapy for primary liver cancer or colorectal-only liver metastases; external pumps for listed chemotherapy, antifungals/antivirals, deferoxamine, heparin, insulin (with detailed diabetes selection criteria), cancer-pain narcotics, pulmonary-hypertension and inotropic agents, and post-op nerve blocks. The core gate in each case is that the drug requires pump-controlled delivery, the device is FDA-approved for that drug, and (for trials/implants) a documented favorable response is shown; uses outside the listed indications (e.g., subacromial pain pumps, intrathecal baclofen for cancer/neuropathic pain, implantable insulin pumps) are excluded as experimental/investigational or not medically necessary. Coverage criteria include: Implantable infusion pumps (general criteria) are medically necessary when ALL of the following are met: (1) the prescribed medication is medically necessary for treatment of the member; (2) administration of the medication requires an implanted infusion pump; AND (3) the pump is FDA-approved for infusion of the prescribed medication being administered.; Intrathecal infusion pump for anti-spasmodic medication (baclofen) is medically necessary when ALL of: (1) member has severe spasticity of cerebral or spinal origin (e.g., spinal cord disease, spinal cord injury, stiff person syndrome, stroke, traumatic brain injury, multiple sclerosis); (2) member requires therapy to sustain upright posture, balance in locomotion, or increased function; (3) documentation that the member's spasticity was unresponsive to other treatment methods (maximum doses of oral baclofen, tizanidine, and/or dantrolene) OR that oral therapy was contraindicated, not tolerated, or ineffective — a trial of oral baclofen is NOT required in children age 12 or less due to increased risk; AND (4) documentation of a favorable response to a trial intrathecal dosage of baclofen before subsequent dosages are considered medically necessary (an implanted pump is NOT medically necessary for members unresponsive to a 100 mcg intrathecal bolus).; Alternative criteria for an anti-spasmodic (intrathecal) infusion pump — medically necessary when BOTH: (1) member has failed a six-week trial of non-invasive spasticity control methods (oral anti-spasmodic drugs) because the methods fail to control spasticity or produce intolerable side effects; AND (2) member has a favorable response to a trial intrathecal dosage of the anti-spasmodic drug prior to pump implantation.; Preliminary trial of intraspinal (epidural or intrathecal) administration of opioid medications (e.g., morphine), ziconotide (Prialt), and/or clonidine is medically necessary when BOTH: (1) member has severe chronic intractable pain of malignant or non-malignant origin unresponsive to less invasive medical therapy; AND (2) member's history indicates inadequate response to non-invasive pain control methods, including systemic opioids. A 1- to 2-day inpatient stay is considered medically necessary for the preliminary trial.; Implantable infusion pump for chronic intractable pain is medically necessary to administer opioid medications (morphine), ziconotide, and/or clonidine intrathecally or epidurally for severe chronic intractable pain when: (1) the preliminary trial of intraspinal opioid administration with a temporary intrathecal/epidural catheter substantiated adequately acceptable pain relief, with at least a 50 percent reduction in pain, an acceptable degree of side effects, and patient acceptance; AND (2) for nonmalignant pain ONLY — a psychological evaluation has been obtained indicating the individual is a favorable candidate for permanent implantation.; Implantable infusion pump for intrahepatic chemotherapy (floxuridine) for liver metastases is medically necessary for members with: primary hepatocellular carcinoma; AND/OR metastatic colorectal cancer where the metastases are limited to the liver. An average 3- to 5-day inpatient hospitalization is considered medically necessary.; External infusion pump is medically necessary DME for administration of certain parenteral anticancer chemotherapy medications (e.g., cladribine, fluorouracil, cytarabine, bleomycin, floxuridine, doxorubicin, vincristine, vinblastine, cisplatin, paclitaxel) if: the prescribed medication is part of an evidence-based chemotherapy regimen; AND parenteral infusion at a strictly controlled rate is necessary to avoid systemic toxicity or adverse effects; AND the medication is administered EITHER by continuous infusion over 8 hours OR by intermittent infusions lasting less than 8 hours that do not require return to the physician's office prior to beginning each infusion.; External infusion pump is medically necessary for administration of certain parenteral antifungal or antiviral medications (e.g., acyclovir, foscarnet, amphotericin B, or ganciclovir).; External infusion pump is medically necessary for administration of chemotherapy for primary hepatocellular carcinoma or colorectal cancer where the tumor is unresectable or the member refuses surgical excision.; External infusion pump is medically necessary for administration of deferoxamine for the treatment of acute iron poisoning and iron overload (only external infusion pumps).; External infusion pump is medically necessary for administration of heparin for the treatment of thromboembolic disease and/or pulmonary embolism (only external infusion pumps used in an institutional setting).; External infusion pump is medically necessary for administration of heparin to adequately anticoagulate women throughout pregnancy (warfarin is not routinely used for this indication).; External infusion pump is medically necessary for administration of insulin for persons with diabetes mellitus who meet the selection criteria for external insulin infusion pumps.; External infusion pump is medically necessary for administration of morphine or other narcotic analgesics (except meperidine) for intractable pain caused by cancer.; External infusion pump is medically necessary for administration of parenteral epoprostenol or treprostinil for persons with pulmonary hypertension.; External infusion pump is medically necessary for administration of parenteral inotropic therapy with dobutamine, milrinone, and/or dopamine.; External infusion pump is medically necessary for administration of post-operative nerve blocks.; External infusion pump is medically necessary for administration of other parenterally administered drugs where an infusion pump is necessary to safely administer the drug at home.; External insulin infusion pump for NEW USERS is medically necessary when ALL of: (1) member is managing diabetes with multiple daily insulin injections (i.e., at least 3 injections per day) with frequent self-adjustments; (2) member has completed a comprehensive diabetes education program; (3) member has documented glucose self-testing an average of at least 4 times per day for the past 2 months OR has been using a continuous glucose monitor (CGM) for the past 2 months; AND (4) member has experienced ONE of the following while on multiple daily injections (at least 3 per day): elevated glycosylated hemoglobin (e.g., HbA1c greater than 7 percent) for at least 6 months; OR ANY of the following for at least 3 months — history of recurrent hypoglycemia (blood glucose less than 70 mg/dL); wide fluctuations in blood glucose before mealtime (pre-prandial levels commonly exceed 140 mg/dL); dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; or history of severe glycemic excursions. (Note: it may be medically necessary to initiate pump therapy during pregnancy earlier than the stated criteria to avoid fetal and maternal complications.); External insulin infusion pump for ESTABLISHED USERS is medically necessary when the member is currently on insulin pump therapy with documented glucose self-testing an average of at least 4 times per day OR is using a continuous glucose monitor (CGM).; Disposable external insulin infusion pumps (e.g., Omnipod DASH, Omnipod 5, V-Go disposable insulin delivery device) are an acceptable alternative for members meeting the medical necessity criteria for external insulin infusion pumps.; Omnipod GO (basal-only device) is medically necessary for members with type 2 diabetes who: do not require bolus or mealtime insulin; have hypersensitivity to an ingredient in all available basal insulin (e.g., long-acting, intermediate-acting); have completed a comprehensive diabetes education program; AND have documented glucose self-testing at least once daily OR are using a continuous glucose monitor (CGM).; General insulin pump requirements (all): a physician with experience managing insulin infusion pumps must order the pump and manage follow-up, working closely with a team (nurses, diabetic educators, dieticians) knowledgeable in insulin pump use; the member must be seen and evaluated by the treating physician at least every 6 months for continued medical necessity; AND the member must demonstrate the ability and commitment to comply with pump care, frequent self-monitoring, and attention to diet and exercise.; Open-loop automated insulin delivery: an FDA-approved CGM and insulin pump with a low glucose suspend feature (e.g., Medtronic MiniMed 530G, 630G) is an equally acceptable alternative to a standard insulin pump and CGM for members meeting the medical necessity criteria for external insulin infusion pumps for diabetes.; Closed-loop (fully automated) system: an FDA-approved CGM and insulin pump with a closed-loop system programmed to automatically adjust delivery of basal insulin based on CGM sensor glucose values (e.g., Beta Bionics iLet Bionic Pancreas) is an equally acceptable alternative for members meeting the medical necessity criteria for external insulin infusion pumps for diabetes.; Hybrid closed-loop (semi-automated, with user input) system: an FDA-approved CGM and insulin pump hybrid closed-loop system (e.g., Insulet's Omnipod 5; Medtronic's MiniMed 670G, 770G, 780G; Tandem's t:slim X2 with Basal-IQ Technology, Tandem Mobi) is an equally acceptable alternative for members meeting the medical necessity criteria for external insulin infusion pumps for diabetes.; Supplies required for the effective use of DME are medically necessary, including medications and biologicals that must be put directly into the equipment to achieve a therapeutic benefit or to assure proper functioning of the equipment.; Replacement of an external insulin pump is medically necessary for children requiring a larger insulin reservoir.; Replacement of infusion pumps that are out of warranty, malfunctioning, and cannot be refurbished is medically necessary.; Replacement of Personal Diabetes Monitors (PDMs) for Omnipod Systems that are out of warranty, malfunctioning, and cannot be refurbished is medically necessary.. Applies to 14 codes: 62360, 62361, 62362, E0782, E0783, E0784, E0787, A4230, A4231, A4232, J0476, J2270, J2272, J2278.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Sufficient medical information in the member's medical record must demonstrate that all applicable coverage criteria are met; there must be information in the member's medical record that supports the medical necessity for the item and substantiates the information on any supplier-prepared statement or treating practitioner's attestation.; Supplier-prepared statements and physician attestations by themselves are NOT sufficient documentation of medical necessity, even if signed by the ordering physician; forms are subject to corroboration with information in the medical record.; Records from suppliers or healthcare professionals with a financial interest in the outcome of the claim are not, by themselves, sufficient for determining that an item is reasonable and necessary.; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.; A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if a supplier bills without first receiving a completed SWO, the claim is denied as not medically necessary.; The SWO must contain ALL of the following: member's name or identification number; the order date; a general description of the item (HCPCS code, narrative, or brand name/model number); all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (each listed separately); for supplies, all concurrently ordered supplies that are separately billed (each listed separately); each item/service individually listing the HCPCS code and quantity to be dispensed; the treating practitioner's name and national provider identifier (NPI); and the treating practitioner's signature.; Treating practitioner is defined as a physician (MD or DO) or a physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered a treating practitioner.; For insulin pumps, documentation of continued medical necessity requires that the member be seen and evaluated by the treating physician at least once every 6 months.; For an implantable pump for nonmalignant chronic intractable pain, a psychological evaluation indicating the individual is a favorable candidate for permanent implantation must be obtained.; For anti-spasmodic and chronic intractable pain implantable pumps, documentation of a favorable response to a trial (preliminary) intrathecal/intraspinal dosage prior to permanent pump implantation is required.
Trap
Policy exclusions and limitations: Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of cancer-related pain.; Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of hydrocephalus.; Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of neuromyotonia (Isaac's syndrome).; Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of rheumatoid arthritis.; Intrathecal baclofen is NOT covered when combined with other agents (e.g., clonidine, hydromorphone, morphine, and ziconotide) because the safety of these combinations has not been established.; Implantable infusion pump for intrathecal or epidural infusion of opioids, ziconotide, and clonidine is NOT covered as a treatment for gastroparesis, and is not covered for all other indications because effectiveness has not been established beyond those listed as covered (note: morphine and ziconotide are the only FDA-approved analgesics for long-term intrathecal infusion).; Implanted infusion pumps are NOT covered for intrahepatic administration of chemotherapy for indications other than those noted as covered, including hepatic metastases from cancers other than colorectal cancer.; 'One-shot' arterial chemotherapy is NOT covered for persons with liver metastases from colorectal cancer.; Implanted infusion pumps are NOT covered for the infusion of heparin for recurrent thromboembolic disease.; Implanted infusion pumps are NOT covered for the infusion of insulin to treat diabetes.; Implanted infusion pumps are NOT covered for the infusion of baclofen for chronic neuropathic pain (e.g., complex regional pain syndrome / reflex sympathetic dystrophy).; External infusion pumps are NOT covered for all other indications, e.g., a subacromial pain pump for pain management following shoulder surgery.; External infusion pumps are NOT covered for diabetes where the listed selection criteria are not met.; Replacement of a functioning insulin pump with an insulin pump that has wireless communication to a glucose monitor is NOT medically necessary, because such wireless communication has not been shown to improve clinical outcomes.; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons with an active infection that may increase the risk of the implantable infusion pump.; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons whose body size is insufficient to support the weight and bulk of the device.; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons with a known allergy or hypersensitivity to the drug being used (e.g., oral baclofen, morphine).; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons with other implanted programmable devices where crosstalk between the devices may inadvertently change the prescription. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0161 — Infusion Pumps

Coverage criteria

  • Implantable infusion pumps (general criteria) are medically necessary when ALL of the following are met: (1) the prescribed medication is medically necessary for treatment of the member; (2) administration of the medication requires an implanted infusion pump; AND (3) the pump is FDA-approved for infusion of the prescribed medication being administered.
  • Intrathecal infusion pump for anti-spasmodic medication (baclofen) is medically necessary when ALL of: (1) member has severe spasticity of cerebral or spinal origin (e.g., spinal cord disease, spinal cord injury, stiff person syndrome, stroke, traumatic brain injury, multiple sclerosis); (2) member requires therapy to sustain upright posture, balance in locomotion, or increased function; (3) documentation that the member's spasticity was unresponsive to other treatment methods (maximum doses of oral baclofen, tizanidine, and/or dantrolene) OR that oral therapy was contraindicated, not tolerated, or ineffective — a trial of oral baclofen is NOT required in children age 12 or less due to increased risk; AND (4) documentation of a favorable response to a trial intrathecal dosage of baclofen before subsequent dosages are considered medically necessary (an implanted pump is NOT medically necessary for members unresponsive to a 100 mcg intrathecal bolus).
  • Alternative criteria for an anti-spasmodic (intrathecal) infusion pump — medically necessary when BOTH: (1) member has failed a six-week trial of non-invasive spasticity control methods (oral anti-spasmodic drugs) because the methods fail to control spasticity or produce intolerable side effects; AND (2) member has a favorable response to a trial intrathecal dosage of the anti-spasmodic drug prior to pump implantation.
  • Preliminary trial of intraspinal (epidural or intrathecal) administration of opioid medications (e.g., morphine), ziconotide (Prialt), and/or clonidine is medically necessary when BOTH: (1) member has severe chronic intractable pain of malignant or non-malignant origin unresponsive to less invasive medical therapy; AND (2) member's history indicates inadequate response to non-invasive pain control methods, including systemic opioids. A 1- to 2-day inpatient stay is considered medically necessary for the preliminary trial.
  • Implantable infusion pump for chronic intractable pain is medically necessary to administer opioid medications (morphine), ziconotide, and/or clonidine intrathecally or epidurally for severe chronic intractable pain when: (1) the preliminary trial of intraspinal opioid administration with a temporary intrathecal/epidural catheter substantiated adequately acceptable pain relief, with at least a 50 percent reduction in pain, an acceptable degree of side effects, and patient acceptance; AND (2) for nonmalignant pain ONLY — a psychological evaluation has been obtained indicating the individual is a favorable candidate for permanent implantation.
  • Implantable infusion pump for intrahepatic chemotherapy (floxuridine) for liver metastases is medically necessary for members with: primary hepatocellular carcinoma; AND/OR metastatic colorectal cancer where the metastases are limited to the liver. An average 3- to 5-day inpatient hospitalization is considered medically necessary.
  • External infusion pump is medically necessary DME for administration of certain parenteral anticancer chemotherapy medications (e.g., cladribine, fluorouracil, cytarabine, bleomycin, floxuridine, doxorubicin, vincristine, vinblastine, cisplatin, paclitaxel) if: the prescribed medication is part of an evidence-based chemotherapy regimen; AND parenteral infusion at a strictly controlled rate is necessary to avoid systemic toxicity or adverse effects; AND the medication is administered EITHER by continuous infusion over 8 hours OR by intermittent infusions lasting less than 8 hours that do not require return to the physician's office prior to beginning each infusion.
  • External infusion pump is medically necessary for administration of certain parenteral antifungal or antiviral medications (e.g., acyclovir, foscarnet, amphotericin B, or ganciclovir).
  • External infusion pump is medically necessary for administration of chemotherapy for primary hepatocellular carcinoma or colorectal cancer where the tumor is unresectable or the member refuses surgical excision.
  • External infusion pump is medically necessary for administration of deferoxamine for the treatment of acute iron poisoning and iron overload (only external infusion pumps).
  • External infusion pump is medically necessary for administration of heparin for the treatment of thromboembolic disease and/or pulmonary embolism (only external infusion pumps used in an institutional setting).
  • External infusion pump is medically necessary for administration of heparin to adequately anticoagulate women throughout pregnancy (warfarin is not routinely used for this indication).
  • External infusion pump is medically necessary for administration of insulin for persons with diabetes mellitus who meet the selection criteria for external insulin infusion pumps.
  • External infusion pump is medically necessary for administration of morphine or other narcotic analgesics (except meperidine) for intractable pain caused by cancer.
  • External infusion pump is medically necessary for administration of parenteral epoprostenol or treprostinil for persons with pulmonary hypertension.
  • External infusion pump is medically necessary for administration of parenteral inotropic therapy with dobutamine, milrinone, and/or dopamine.
  • External infusion pump is medically necessary for administration of post-operative nerve blocks.
  • External infusion pump is medically necessary for administration of other parenterally administered drugs where an infusion pump is necessary to safely administer the drug at home.
  • External insulin infusion pump for NEW USERS is medically necessary when ALL of: (1) member is managing diabetes with multiple daily insulin injections (i.e., at least 3 injections per day) with frequent self-adjustments; (2) member has completed a comprehensive diabetes education program; (3) member has documented glucose self-testing an average of at least 4 times per day for the past 2 months OR has been using a continuous glucose monitor (CGM) for the past 2 months; AND (4) member has experienced ONE of the following while on multiple daily injections (at least 3 per day): elevated glycosylated hemoglobin (e.g., HbA1c greater than 7 percent) for at least 6 months; OR ANY of the following for at least 3 months — history of recurrent hypoglycemia (blood glucose less than 70 mg/dL); wide fluctuations in blood glucose before mealtime (pre-prandial levels commonly exceed 140 mg/dL); dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; or history of severe glycemic excursions. (Note: it may be medically necessary to initiate pump therapy during pregnancy earlier than the stated criteria to avoid fetal and maternal complications.)
  • External insulin infusion pump for ESTABLISHED USERS is medically necessary when the member is currently on insulin pump therapy with documented glucose self-testing an average of at least 4 times per day OR is using a continuous glucose monitor (CGM).
  • Disposable external insulin infusion pumps (e.g., Omnipod DASH, Omnipod 5, V-Go disposable insulin delivery device) are an acceptable alternative for members meeting the medical necessity criteria for external insulin infusion pumps.
  • Omnipod GO (basal-only device) is medically necessary for members with type 2 diabetes who: do not require bolus or mealtime insulin; have hypersensitivity to an ingredient in all available basal insulin (e.g., long-acting, intermediate-acting); have completed a comprehensive diabetes education program; AND have documented glucose self-testing at least once daily OR are using a continuous glucose monitor (CGM).
  • General insulin pump requirements (all): a physician with experience managing insulin infusion pumps must order the pump and manage follow-up, working closely with a team (nurses, diabetic educators, dieticians) knowledgeable in insulin pump use; the member must be seen and evaluated by the treating physician at least every 6 months for continued medical necessity; AND the member must demonstrate the ability and commitment to comply with pump care, frequent self-monitoring, and attention to diet and exercise.
  • Open-loop automated insulin delivery: an FDA-approved CGM and insulin pump with a low glucose suspend feature (e.g., Medtronic MiniMed 530G, 630G) is an equally acceptable alternative to a standard insulin pump and CGM for members meeting the medical necessity criteria for external insulin infusion pumps for diabetes.
  • Closed-loop (fully automated) system: an FDA-approved CGM and insulin pump with a closed-loop system programmed to automatically adjust delivery of basal insulin based on CGM sensor glucose values (e.g., Beta Bionics iLet Bionic Pancreas) is an equally acceptable alternative for members meeting the medical necessity criteria for external insulin infusion pumps for diabetes.
  • Hybrid closed-loop (semi-automated, with user input) system: an FDA-approved CGM and insulin pump hybrid closed-loop system (e.g., Insulet's Omnipod 5; Medtronic's MiniMed 670G, 770G, 780G; Tandem's t:slim X2 with Basal-IQ Technology, Tandem Mobi) is an equally acceptable alternative for members meeting the medical necessity criteria for external insulin infusion pumps for diabetes.
  • Supplies required for the effective use of DME are medically necessary, including medications and biologicals that must be put directly into the equipment to achieve a therapeutic benefit or to assure proper functioning of the equipment.
  • Replacement of an external insulin pump is medically necessary for children requiring a larger insulin reservoir.
  • Replacement of infusion pumps that are out of warranty, malfunctioning, and cannot be refurbished is medically necessary.
  • Replacement of Personal Diabetes Monitors (PDMs) for Omnipod Systems that are out of warranty, malfunctioning, and cannot be refurbished is medically necessary.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Sufficient medical information in the member's medical record must demonstrate that all applicable coverage criteria are met; there must be information in the member's medical record that supports the medical necessity for the item and substantiates the information on any supplier-prepared statement or treating practitioner's attestation.
  • Supplier-prepared statements and physician attestations by themselves are NOT sufficient documentation of medical necessity, even if signed by the ordering physician; forms are subject to corroboration with information in the medical record.
  • Records from suppliers or healthcare professionals with a financial interest in the outcome of the claim are not, by themselves, sufficient for determining that an item is reasonable and necessary.
  • A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.
  • A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if a supplier bills without first receiving a completed SWO, the claim is denied as not medically necessary.
  • The SWO must contain ALL of the following: member's name or identification number; the order date; a general description of the item (HCPCS code, narrative, or brand name/model number); all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (each listed separately); for supplies, all concurrently ordered supplies that are separately billed (each listed separately); each item/service individually listing the HCPCS code and quantity to be dispensed; the treating practitioner's name and national provider identifier (NPI); and the treating practitioner's signature.
  • Treating practitioner is defined as a physician (MD or DO) or a physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered a treating practitioner.
  • For insulin pumps, documentation of continued medical necessity requires that the member be seen and evaluated by the treating physician at least once every 6 months.
  • For an implantable pump for nonmalignant chronic intractable pain, a psychological evaluation indicating the individual is a favorable candidate for permanent implantation must be obtained.
  • For anti-spasmodic and chronic intractable pain implantable pumps, documentation of a favorable response to a trial (preliminary) intrathecal/intraspinal dosage prior to permanent pump implantation is required.

Frequently asked questions

When does Aetna cover Infusion Pumps (CPT 62360), and what gets it denied?
Aetna CPB 0161 covers infusion pumps as medically necessary only for specific drug-and-condition pairings: implantable pumps for intrathecal baclofen in severe spasticity, intrathecal/epidural opioids (morphine), ziconotide or clonidine for severe chronic intractable pain after a successful trial, and intrahepatic floxuridine chemotherapy for primary liver cancer or colorectal-only liver metastases; external pumps for listed chemotherapy, antifungals/antivirals, deferoxamine, heparin, insulin (with detailed diabetes selection criteria), cancer-pain narcotics, pulmonary-hypertension and inotropic agents, and post-op nerve blocks. The core gate in each case is that the drug requires pump-controlled delivery, the device is FDA-approved for that drug, and (for trials/implants) a documented favorable response is shown; uses outside the listed indications (e.g., subacromial pain pumps, intrathecal baclofen for cancer/neuropathic pain, implantable insulin pumps) are excluded as experimental/investigational or not medically necessary. Coverage criteria include: Implantable infusion pumps (general criteria) are medically necessary when ALL of the following are met: (1) the prescribed medication is medically necessary for treatment of the member; (2) administration of the medication requires an implanted infusion pump; AND (3) the pump is FDA-approved for infusion of the prescribed medication being administered.; Intrathecal infusion pump for anti-spasmodic medication (baclofen) is medically necessary when ALL of: (1) member has severe spasticity of cerebral or spinal origin (e.g., spinal cord disease, spinal cord injury, stiff person syndrome, stroke, traumatic brain injury, multiple sclerosis); (2) member requires therapy to sustain upright posture, balance in locomotion, or increased function; (3) documentation that the member's spasticity was unresponsive to other treatment methods (maximum doses of oral baclofen, tizanidine, and/or dantrolene) OR that oral therapy was contraindicated, not tolerated, or ineffective — a trial of oral baclofen is NOT required in children age 12 or less due to increased risk; AND (4) documentation of a favorable response to a trial intrathecal dosage of baclofen before subsequent dosages are considered medically necessary (an implanted pump is NOT medically necessary for members unresponsive to a 100 mcg intrathecal bolus).; Alternative criteria for an anti-spasmodic (intrathecal) infusion pump — medically necessary when BOTH: (1) member has failed a six-week trial of non-invasive spasticity control methods (oral anti-spasmodic drugs) because the methods fail to control spasticity or produce intolerable side effects; AND (2) member has a favorable response to a trial intrathecal dosage of the anti-spasmodic drug prior to pump implantation.; Preliminary trial of intraspinal (epidural or intrathecal) administration of opioid medications (e.g., morphine), ziconotide (Prialt), and/or clonidine is medically necessary when BOTH: (1) member has severe chronic intractable pain of malignant or non-malignant origin unresponsive to less invasive medical therapy; AND (2) member's history indicates inadequate response to non-invasive pain control methods, including systemic opioids. A 1- to 2-day inpatient stay is considered medically necessary for the preliminary trial.; Implantable infusion pump for chronic intractable pain is medically necessary to administer opioid medications (morphine), ziconotide, and/or clonidine intrathecally or epidurally for severe chronic intractable pain when: (1) the preliminary trial of intraspinal opioid administration with a temporary intrathecal/epidural catheter substantiated adequately acceptable pain relief, with at least a 50 percent reduction in pain, an acceptable degree of side effects, and patient acceptance; AND (2) for nonmalignant pain ONLY — a psychological evaluation has been obtained indicating the individual is a favorable candidate for permanent implantation.; Implantable infusion pump for intrahepatic chemotherapy (floxuridine) for liver metastases is medically necessary for members with: primary hepatocellular carcinoma; AND/OR metastatic colorectal cancer where the metastases are limited to the liver. An average 3- to 5-day inpatient hospitalization is considered medically necessary.; External infusion pump is medically necessary DME for administration of certain parenteral anticancer chemotherapy medications (e.g., cladribine, fluorouracil, cytarabine, bleomycin, floxuridine, doxorubicin, vincristine, vinblastine, cisplatin, paclitaxel) if: the prescribed medication is part of an evidence-based chemotherapy regimen; AND parenteral infusion at a strictly controlled rate is necessary to avoid systemic toxicity or adverse effects; AND the medication is administered EITHER by continuous infusion over 8 hours OR by intermittent infusions lasting less than 8 hours that do not require return to the physician's office prior to beginning each infusion.; External infusion pump is medically necessary for administration of certain parenteral antifungal or antiviral medications (e.g., acyclovir, foscarnet, amphotericin B, or ganciclovir).; External infusion pump is medically necessary for administration of chemotherapy for primary hepatocellular carcinoma or colorectal cancer where the tumor is unresectable or the member refuses surgical excision.; External infusion pump is medically necessary for administration of deferoxamine for the treatment of acute iron poisoning and iron overload (only external infusion pumps).; External infusion pump is medically necessary for administration of heparin for the treatment of thromboembolic disease and/or pulmonary embolism (only external infusion pumps used in an institutional setting).; External infusion pump is medically necessary for administration of heparin to adequately anticoagulate women throughout pregnancy (warfarin is not routinely used for this indication).; External infusion pump is medically necessary for administration of insulin for persons with diabetes mellitus who meet the selection criteria for external insulin infusion pumps.; External infusion pump is medically necessary for administration of morphine or other narcotic analgesics (except meperidine) for intractable pain caused by cancer.; External infusion pump is medically necessary for administration of parenteral epoprostenol or treprostinil for persons with pulmonary hypertension.; External infusion pump is medically necessary for administration of parenteral inotropic therapy with dobutamine, milrinone, and/or dopamine.; External infusion pump is medically necessary for administration of post-operative nerve blocks.; External infusion pump is medically necessary for administration of other parenterally administered drugs where an infusion pump is necessary to safely administer the drug at home.; External insulin infusion pump for NEW USERS is medically necessary when ALL of: (1) member is managing diabetes with multiple daily insulin injections (i.e., at least 3 injections per day) with frequent self-adjustments; (2) member has completed a comprehensive diabetes education program; (3) member has documented glucose self-testing an average of at least 4 times per day for the past 2 months OR has been using a continuous glucose monitor (CGM) for the past 2 months; AND (4) member has experienced ONE of the following while on multiple daily injections (at least 3 per day): elevated glycosylated hemoglobin (e.g., HbA1c greater than 7 percent) for at least 6 months; OR ANY of the following for at least 3 months — history of recurrent hypoglycemia (blood glucose less than 70 mg/dL); wide fluctuations in blood glucose before mealtime (pre-prandial levels commonly exceed 140 mg/dL); dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; or history of severe glycemic excursions. (Note: it may be medically necessary to initiate pump therapy during pregnancy earlier than the stated criteria to avoid fetal and maternal complications.); External insulin infusion pump for ESTABLISHED USERS is medically necessary when the member is currently on insulin pump therapy with documented glucose self-testing an average of at least 4 times per day OR is using a continuous glucose monitor (CGM).; Disposable external insulin infusion pumps (e.g., Omnipod DASH, Omnipod 5, V-Go disposable insulin delivery device) are an acceptable alternative for members meeting the medical necessity criteria for external insulin infusion pumps.; Omnipod GO (basal-only device) is medically necessary for members with type 2 diabetes who: do not require bolus or mealtime insulin; have hypersensitivity to an ingredient in all available basal insulin (e.g., long-acting, intermediate-acting); have completed a comprehensive diabetes education program; AND have documented glucose self-testing at least once daily OR are using a continuous glucose monitor (CGM).; General insulin pump requirements (all): a physician with experience managing insulin infusion pumps must order the pump and manage follow-up, working closely with a team (nurses, diabetic educators, dieticians) knowledgeable in insulin pump use; the member must be seen and evaluated by the treating physician at least every 6 months for continued medical necessity; AND the member must demonstrate the ability and commitment to comply with pump care, frequent self-monitoring, and attention to diet and exercise.; Open-loop automated insulin delivery: an FDA-approved CGM and insulin pump with a low glucose suspend feature (e.g., Medtronic MiniMed 530G, 630G) is an equally acceptable alternative to a standard insulin pump and CGM for members meeting the medical necessity criteria for external insulin infusion pumps for diabetes.; Closed-loop (fully automated) system: an FDA-approved CGM and insulin pump with a closed-loop system programmed to automatically adjust delivery of basal insulin based on CGM sensor glucose values (e.g., Beta Bionics iLet Bionic Pancreas) is an equally acceptable alternative for members meeting the medical necessity criteria for external insulin infusion pumps for diabetes.; Hybrid closed-loop (semi-automated, with user input) system: an FDA-approved CGM and insulin pump hybrid closed-loop system (e.g., Insulet's Omnipod 5; Medtronic's MiniMed 670G, 770G, 780G; Tandem's t:slim X2 with Basal-IQ Technology, Tandem Mobi) is an equally acceptable alternative for members meeting the medical necessity criteria for external insulin infusion pumps for diabetes.; Supplies required for the effective use of DME are medically necessary, including medications and biologicals that must be put directly into the equipment to achieve a therapeutic benefit or to assure proper functioning of the equipment.; Replacement of an external insulin pump is medically necessary for children requiring a larger insulin reservoir.; Replacement of infusion pumps that are out of warranty, malfunctioning, and cannot be refurbished is medically necessary.; Replacement of Personal Diabetes Monitors (PDMs) for Omnipod Systems that are out of warranty, malfunctioning, and cannot be refurbished is medically necessary.. Applies to 14 codes: 62360, 62361, 62362, E0782, E0783, E0784, E0787, A4230, A4231, A4232, J0476, J2270, J2272, J2278. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Sufficient medical information in the member's medical record must demonstrate that all applicable coverage criteria are met; there must be information in the member's medical record that supports the medical necessity for the item and substantiates the information on any supplier-prepared statement or treating practitioner's attestation.; Supplier-prepared statements and physician attestations by themselves are NOT sufficient documentation of medical necessity, even if signed by the ordering physician; forms are subject to corroboration with information in the medical record.; Records from suppliers or healthcare professionals with a financial interest in the outcome of the claim are not, by themselves, sufficient for determining that an item is reasonable and necessary.; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.; A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if a supplier bills without first receiving a completed SWO, the claim is denied as not medically necessary.; The SWO must contain ALL of the following: member's name or identification number; the order date; a general description of the item (HCPCS code, narrative, or brand name/model number); all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (each listed separately); for supplies, all concurrently ordered supplies that are separately billed (each listed separately); each item/service individually listing the HCPCS code and quantity to be dispensed; the treating practitioner's name and national provider identifier (NPI); and the treating practitioner's signature.; Treating practitioner is defined as a physician (MD or DO) or a physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered a treating practitioner.; For insulin pumps, documentation of continued medical necessity requires that the member be seen and evaluated by the treating physician at least once every 6 months.; For an implantable pump for nonmalignant chronic intractable pain, a psychological evaluation indicating the individual is a favorable candidate for permanent implantation must be obtained.; For anti-spasmodic and chronic intractable pain implantable pumps, documentation of a favorable response to a trial (preliminary) intrathecal/intraspinal dosage prior to permanent pump implantation is required. Policy exclusions and limitations: Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of cancer-related pain.; Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of hydrocephalus.; Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of neuromyotonia (Isaac's syndrome).; Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of rheumatoid arthritis.; Intrathecal baclofen is NOT covered when combined with other agents (e.g., clonidine, hydromorphone, morphine, and ziconotide) because the safety of these combinations has not been established.; Implantable infusion pump for intrathecal or epidural infusion of opioids, ziconotide, and clonidine is NOT covered as a treatment for gastroparesis, and is not covered for all other indications because effectiveness has not been established beyond those listed as covered (note: morphine and ziconotide are the only FDA-approved analgesics for long-term intrathecal infusion).; Implanted infusion pumps are NOT covered for intrahepatic administration of chemotherapy for indications other than those noted as covered, including hepatic metastases from cancers other than colorectal cancer.; 'One-shot' arterial chemotherapy is NOT covered for persons with liver metastases from colorectal cancer.; Implanted infusion pumps are NOT covered for the infusion of heparin for recurrent thromboembolic disease.; Implanted infusion pumps are NOT covered for the infusion of insulin to treat diabetes.; Implanted infusion pumps are NOT covered for the infusion of baclofen for chronic neuropathic pain (e.g., complex regional pain syndrome / reflex sympathetic dystrophy).; External infusion pumps are NOT covered for all other indications, e.g., a subacromial pain pump for pain management following shoulder surgery.; External infusion pumps are NOT covered for diabetes where the listed selection criteria are not met.; Replacement of a functioning insulin pump with an insulin pump that has wireless communication to a glucose monitor is NOT medically necessary, because such wireless communication has not been shown to improve clinical outcomes.; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons with an active infection that may increase the risk of the implantable infusion pump.; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons whose body size is insufficient to support the weight and bulk of the device.; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons with a known allergy or hypersensitivity to the drug being used (e.g., oral baclofen, morphine).; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons with other implanted programmable devices where crosstalk between the devices may inadvertently change the prescription. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Infusion Pumps?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Sufficient medical information in the member's medical record must demonstrate that all applicable coverage criteria are met; there must be information in the member's medical record that supports the medical necessity for the item and substantiates the information on any supplier-prepared statement or treating practitioner's attestation.; Supplier-prepared statements and physician attestations by themselves are NOT sufficient documentation of medical necessity, even if signed by the ordering physician; forms are subject to corroboration with information in the medical record.; Records from suppliers or healthcare professionals with a financial interest in the outcome of the claim are not, by themselves, sufficient for determining that an item is reasonable and necessary.; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.; A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if a supplier bills without first receiving a completed SWO, the claim is denied as not medically necessary.; The SWO must contain ALL of the following: member's name or identification number; the order date; a general description of the item (HCPCS code, narrative, or brand name/model number); all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (each listed separately); for supplies, all concurrently ordered supplies that are separately billed (each listed separately); each item/service individually listing the HCPCS code and quantity to be dispensed; the treating practitioner's name and national provider identifier (NPI); and the treating practitioner's signature.; Treating practitioner is defined as a physician (MD or DO) or a physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered a treating practitioner.; For insulin pumps, documentation of continued medical necessity requires that the member be seen and evaluated by the treating physician at least once every 6 months.; For an implantable pump for nonmalignant chronic intractable pain, a psychological evaluation indicating the individual is a favorable candidate for permanent implantation must be obtained.; For anti-spasmodic and chronic intractable pain implantable pumps, documentation of a favorable response to a trial (preliminary) intrathecal/intraspinal dosage prior to permanent pump implantation is required.
What does Aetna exclude for Infusion Pumps?
Policy exclusions and limitations: Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of cancer-related pain.; Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of hydrocephalus.; Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of neuromyotonia (Isaac's syndrome).; Intrathecal baclofen is considered experimental/investigational and NOT covered for the treatment of rheumatoid arthritis.; Intrathecal baclofen is NOT covered when combined with other agents (e.g., clonidine, hydromorphone, morphine, and ziconotide) because the safety of these combinations has not been established.; Implantable infusion pump for intrathecal or epidural infusion of opioids, ziconotide, and clonidine is NOT covered as a treatment for gastroparesis, and is not covered for all other indications because effectiveness has not been established beyond those listed as covered (note: morphine and ziconotide are the only FDA-approved analgesics for long-term intrathecal infusion).; Implanted infusion pumps are NOT covered for intrahepatic administration of chemotherapy for indications other than those noted as covered, including hepatic metastases from cancers other than colorectal cancer.; 'One-shot' arterial chemotherapy is NOT covered for persons with liver metastases from colorectal cancer.; Implanted infusion pumps are NOT covered for the infusion of heparin for recurrent thromboembolic disease.; Implanted infusion pumps are NOT covered for the infusion of insulin to treat diabetes.; Implanted infusion pumps are NOT covered for the infusion of baclofen for chronic neuropathic pain (e.g., complex regional pain syndrome / reflex sympathetic dystrophy).; External infusion pumps are NOT covered for all other indications, e.g., a subacromial pain pump for pain management following shoulder surgery.; External infusion pumps are NOT covered for diabetes where the listed selection criteria are not met.; Replacement of a functioning insulin pump with an insulin pump that has wireless communication to a glucose monitor is NOT medically necessary, because such wireless communication has not been shown to improve clinical outcomes.; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons with an active infection that may increase the risk of the implantable infusion pump.; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons whose body size is insufficient to support the weight and bulk of the device.; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons with a known allergy or hypersensitivity to the drug being used (e.g., oral baclofen, morphine).; Implantable infusion pumps are NOT medically necessary (contraindicated) for persons with other implanted programmable devices where crosstalk between the devices may inadvertently change the prescription. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0161 — Infusion Pumps

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0161 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.