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Official Description

External ambulatory infusion pump, insulin
Short Descr Ext amb infusn pump insulin
Coverage Special coverage instructions apply
Pricing Indicator(s) 36 – Supplies And Surgical Dressings - Capped rental DME (price subject to floors and ceilings)
MPI A – Not applicable, as HCPCS priced under one methodology
CIM 60-14
BETOS D1E – Other DME
TOS Code(s) R – Rental of DME
Added Date 1/1/1996
APC Status Indicator Non-Implantable Durable Medical Equipment
MUE 0
MUE 1
IOM 100-03, 4, 280.14
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
RR Rental (use the 'rr' modifier when dme is to be rented)
KJ Dmepos item, parenteral enteral nutrition (pen) pump or capped rental, months four to fifteen
KI Dmepos item, second or third month rental
KH Dmepos item, initial claim, purchase or first month rental
GZ Item or service expected to be denied as not reasonable and necessary
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CG Policy criteria applied
GA Waiver of liability statement issued as required by payer policy, individual case
GW Service not related to the hospice patient's terminal condition
JB Administered subcutaneously
KX Requirements specified in the medical policy have been met
MS Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
NU New equipment
RA Replacement of a dme, orthotic or prosthetic item
Date
Action
Notes
1996-01-01 Added Code added 1/1/1996
Code
Description
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