External Infusion Pumps - JA DME

For continued coverage of an external insulin pump and supplies, the treating physician must see the patient at least every 3 months. Documentation must be available upon request or in the event of a review.

Coverage of drugs used with external infusion pumps may have differing denials. It is important for suppliers of these drugs to understand issues related to coverage and denials.

• Suppliers must ensure that beneficiary-owned equipment information is on file with Medicare Fee-for-Service (FFS) to avoid denials. Additional documentation to support medical necessity is required for supplies and accessories when the base equipment, such as a pump, has been provided and was not initially paid for by Medicare FFS.
  • Claims submitted for drugs and supplies used with beneficiary-owned equipment require three elements as listed below.
    • Healthcare Common Procedure Coding System (HCPCS) code of base equipment (pump); and
    • A notation that the pump is beneficiary-owned; and
    • Approximate date the beneficiary obtained the pump
    • Example narrative for EIP supplies for a beneficiary owned pump:
    • BENEFICIARY OWNED K0455 PURCHASED MARCH 2016

• JK - One month supply or less of drug or biological
  • Effective for use for J1817 on April 1, 2023
  • May be used for May and June date of service
  • Required for use July 1, 2023
    • For all insulin administered through DME (J1811, J1813, and J1817)
• JL - Three-month supply of drug or biological
  • Effective for use for J1817 on April 1, 2023
  • Required for use July 1, 2023
    • Required for all insulin administered through DME (J1811, J1813, and J1817)
  • May and June date of service with JL modifier will be returned as un-processable
• Note: Any drug or biological supply billed in excess of one-month, append JL modifier
• See the MLN Fact Sheet for more information
• JW - drug amount discarded/not administered to any patient
  • Indicated for discarded drugs and biologicals from "single use vials or single use packages."
• JZ - zero drug amount discarded/not administered to any patient
  • Effective for use January 1, 2023, and,
  • Required for use on applicable claims with dates of service July 1, 2023
  • Indicated when there are no discarded amounts from "single use vials or single use packages."
• KX - all the coverage criteria in the "Coverage Indications, Limitations, and/or Medical Necessity" section in the related LCD have been met.
  • Required for use on claims with a receipt date March 1, 2023, and after
• GA - policy criteria is not met. Waiver of Liability statement on file. Valid Advance Beneficiary Notice of Noncoverage (ABN) obtained.
  • Required for use on claims with a receipt date March 1, 2023, and after, if the KX modifier does not apply, and a valid ABN is received.
• GZ - item or service expected to be denied as not reasonable or necessary, no valid ABN on file.
  • Required for use on claims with a receipt date March 1, 2023, and after, if the KX modifier does not apply, and no ABN is received.