KMAP BULLETIN: Updated Criteria Guidance for Coverage of Insulin Infusion Pumps and Supplies

Date: 07/25/24

Insulin pumps and limited supplies are covered for members meeting the Kansas Medical Assistance Program (KMAP) criteria and have a current diagnosis of Insulin Dependent Type I Diabetes Mellitus. Prior Authorization (PA) must be submitted and approved prior to placement of the pump. Insulin pumps are non-covered for MediKan. Insulin pumps are limited to no more than one every three years and restricted to place of service (POS) Home (12). KMAP will make the final decision to purchase or rent an insulin pump. KMAP will also determine the length of the PA but, it will be no more than 12 months at a time.

Replacements are only allowed for lost, stolen, or non-functioning pumps damaged beyond repair. For lost or stolen pumps, a police report must be submitted to KMAP. Replacements are non-covered for upgrading.

All documentation regarding insulin pumps must be written and signed by the treating physician and submitted to KMAP by the Durable Medical Equipment (DME) provider. All correspondence will be with the DME provider. Documentation submitted to KMAP by anyone other than the DME provider will be returned unprocessed.

~~Continuous Glucose Monitoring is non-covered by KMAP.~~

If for any reason the member no longer needs the insulin pump, it must be surrendered to the KMAP Kansas Equipment Exchange Program along with any unused supplies.

Insulin Pump Request Criteria (member has never been on an insulin pump)

Member must meet all the following to be eligible for an insulin pump:

Diagnosis of Type I Diabetes Mellitus (insulin dependent).
Currently has one of the following diagnoses:

E10.10	E10.11	E10.21	E10.22	E10.2311	E10.2312
E10.2313	E10.2319	E10.29	E10.311	E10.319	E10.3291
E10.3292	E10.3293	E10.3299	E10.3311	E10.3312	E10.3313
E10.3319	E10.3411	E10.3412	E10.3413	E10.3419	E10.3491
E10.3492	E10.3493	E10.3499	E10.3511	E10.3512	E10.3513
E10.3519	E10.3591	E10.3592	E10.3593	E10.3599	E10.36
E10.37x1	E10.37x2	E10.37x3	E10.37x9	E10.39	E10.40
E10.41	E10.42	E10.43	E10.44	E10.49	E10.51
E10.52	E10.59	E10.610	E10.618	E10.620	E10.621
E10.622	E10.628	E10.630	E10.638	E10.641	E10.649
E10.65	E10.69	E10.8	E10.9

Serum C-Peptide level less than or equal to 110% of the lower limit of normal of the laboratory’s measurement method (drawn within 60 days prior to request).
For members diagnosed less than five years, a comprehensive diabetes education program must have been completed (completion and contents of training must be submitted).
For members diagnosed more than five years, a physician may confirm education has been completed.
Member must have been on a program of multiple daily injections of insulin (at least three injections per day) with frequent self-adjustments of the insulin dose for at least six months immediately prior to the request of the insulin pump.
Documented frequency of glucose self-testing on average at least
four times per day during the immediate two months prior to the pump request.
Documented glycosylated hemoglobin level (HbA1C) greater than 7% (drawn within 60 days prior to request).
History of recurring hypoglycemia.
Wide fluctuations (plus or minus 100 mg/dL) in blood glucose before mealtime.
Dawn Phenomenon with fasting blood sugars frequently exceeding 200 mg/dL.
History of severe glycemic excursions (plus or minus 200 mg/dL).
Evaluated in person by the treating physician at least every three months.

Insulin Pump Supplies

For members that are not currently using an insulin pump, the initial request and the supplies must be requested on the same PA.
If the initial pump request is approved, the supplies will be covered if request.

Batteries of any kind are non-covered.

PAs for supplies will be given for up to 12 months at a time.

Only one type of infusion set is allowed (needle or non-needle).

Supplies are limited to no more than 10 per month per member.

Members entering KMAP who are currently using an insulin pump that was purchased by other entities must meet all the following (documentation must be submitted to address all points):

Documented frequency of glucose self-testing an average of at least
four times per day during the two months immediately prior to the date of request.
Evaluated in person by the treating physician at least every three months.
Diagnosis of Insulin Dependent Diabetes Mellitus Type I.
Letter of Medical Necessity discussing how long the member has been on an insulin pump and why they were originally put on a pump.
Current HgbA1C level drawn within 60 days immediately
prior to date of request.

With each 12-month PA request for supplies (renewals only), the following must be submitted:

HgbA1C level drawn within 60 days immediately prior to date of request.
New prescription written by treating physician.
Confirmation member is being seen by treating physician at least every three months.