4.1 External
Infusion Pump (EIP)
4.1.1 Claims may be reimbursed for
medically necessary United States (US) Food and Drug Administration (FDA)
approved EIPs when used according to label specifications in delivering
continuous or intermittent drug therapy on an inpatient or outpatient
basis.
4.1.2 Supplies for the effective
use of the EIP must be FDA approved. Such supplies include those
drugs and biologicals prescribed for usage directly into the EIP
in order to achieve the therapeutic benefit of the EIP, or to assure
the proper functioning of the equipment.
4.1.3 EIPs and
otherwise covered medical supplies required in the administration
of the drug therapy performed in the home are covered.
4.1.4 Other medical conditions requiring
the use of an infusion of medicine from a FDA-approved EIP may be cost
shared when medical review determines the treatment to be medically
necessary and generally accepted medical practice. Examples of covered
medical conditions requiring the use of FDA-approved EIPs.
4.1.4.1 Cancer chemotherapy agents.
4.1.4.2 Morphine when used in the treatment
of intractable pain.
4.1.4.3 Desferoxamine.
4.1.4.4 Insulin: When the patient has
one of the following indications (list is all-inclusive):
• When the diagnosis is insulin
dependent Type 1 diabetes mellitus and there is documentation by
the physician of poor diabetic control; OR
• For Cystic Fibrosis-Related
Diabetes (CFRD) under the rare disease policy as described in
Chapter 1, Section 3.1; OR
• For Type 2 diabetes mellitus
when there is documentation by the physician of poor diabetic control
AND the patient has failed to achieve glycemic control after six
months of Multiple Daily Injection (MDI) therapy.
4.1.4.5 Antibiotic therapy.
4.1.4.6 Heparin therapy in treatment
of thromboemobolic disease.
4.1.5 EIPs,
to include disposable EIPs that are medical supplies, are cost-shared
as Durable Medical Equipment (DME). (See the TRICARE Reimbursement
Manual (TRM),
Chapter 2, Addendum A for cost-sharing and copayment
amounts; see TRM,
Chapter 1, Section 11 for more information
on reimbursement of DME.)
4.2 Transdermal
Insulin Delivery System
The Valeritas
V-Go™ Insulin Delivery Device (V-Go) is FDA approved as a Class
II, EIIP for the continuous subcutaneous delivery of insulin in
preset basal rates with on-demand bolus dosing for adult patients
requiring insulin. The V-Go is a fully mechanical device using a
compressed spring and does not require electronics, batteries, or
software. It is a patient fillable, single-use, completely disposable
insulin infusion device with an integrated stainless steel subcutaneous
needle. The device is used for the subcutaneous delivery of 24 hours
of U-100 fast-acting insulin (i.e., Humalog® [insulin lispro] and
Novolog® [insulin aspart]). Documentation of the following must be
provided in order for TRICARE to consider a claim for payment:
4.2.1 The patient
has Type 2 diabetes mellitus; and
4.2.2 The patient
does not need more than 40 units of basal insulin daily and the
patient does not need more than 36 units of bolus insulin daily;
and
4.2.3 The patient does not need less
than two unit increments of bolus dosing; and
4.2.4 The patient
has been maintained on stable basal insulin for at least three months
(at dosages of 20U, 30U, or 40U); and
4.2.5 The patient
has been using prandial insulin for at least three months.
4.3 Implantable Infusion Pump (IIP)
Claims may be reimbursed for
services and supplies related to the use of medically necessary,
FDA approved IIPs when used according to pump label specifications.
This may include but is not limited to implantation, refilling, servicing,
maintenance, and removal of the pump and/or accessories. Uses may
include but are not limited to the following (please note “EXCLUSIONS”
and “EFFECTIVE DATES” listed below):
4.3.1 Treatment
of primary liver cancer or metastatic colorectal liver cancer where
the metastases are limited to the liver with continuous hepatic
artery infusions of chemotherapeutic agents (e.g., floxuridine,
doxorubicin hydrochloride, cisplatin, methotrexate, with bacteriostatic
water or physiologic saline and/or heparin);
4.3.2 Treatment of osteomyelitis
with administration of antibiotics (e.g., clindamycin);
4.3.3 Treatment of chronic intractable
pain of malignant or nonmalignant origin by administration of opioid drugs
(e.g., morphine) intrathecally or epidurally in patients who have
a life expectancy of at least three months and who have not responded
to less invasive medical therapy. Documentation of the following
must be provided in order for TRICARE to consider a claim for payment:
4.3.3.1 Inadequate response to noninvasive
methods of pain management such as systemic opioids, including attempts
to eliminate physical and behavioral abnormalities which may cause
an exaggerated reaction to pain, and
4.3.3.2 A preliminary trial of intraspinal
opioid with a temporary intrathecal/epidural catheter to evaluate pain
relief, side effects, and patient acceptance.
4.3.4 Treatment of chronic intractable
spasticity with administration of anti-spasmodic drugs (e.g., baclofen) in
patients who have proven unresponsive to less invasive medical therapy.
The following must be provided in order to consider a claim for
payment:
4.3.4.1 Documentation of inadequate
control of spasticity or intolerable side effects resulting from
at least a six week trial of noninvasive methods of spasm control
with drugs such as oral antispasmodics alone or combined with anticonvulsants
(depending on the disease progression and the patient’s symptoms),
and
4.3.4.2 Documentation of a favorable
response to a trial intrathecal dose of the antispasmodic drug prior
to pump implantation;
4.3.5 Second
level review is required for all other IIP uses. Reimbursement may
be considered for other uses of IIPs (not specifically excluded
in
paragraph 6.0)
with documentation of the following:
4.3.5.1 The medical necessity of the
drug;
4.3.5.2 The medical necessity and appropriateness
of an IIP to deliver the drug; and
4.3.5.3 The IIP use adheres to the
FDA approved labeling for the pump and the drug.
4.4 Off-Label Uses For EIPs And
IIPs
Effective July 27, 2012, when
provided in accordance with
Section 5.1,
EIPs and IIPs, including related services and supplies, provided
for off-label uses may be cost-shared unless such use is specifically
excluded by TRICARE statute, regulation, or policy.