My presentation is in a series on reimbursement, from continuous glucose meters, to diabetes telemedicine and prevention, to artificial pancreas. I'm posting the deck I will present, on insulin pump policy: here.
Some key points:
- Medicare is a defined benefit program, and insulin pumps and their insulin are under the benefit for DME (including wheelchairs, etc).
- There's one legacy pump code, E0784, priced at about $5400 regardless of brand or pump capabilities.
- You have to be doing demonstrably badly enough on insulin before Medicare covers a pump.
- Due to 2003 rules, insulin pricing for pump-based insulin had gotten badly out of whack with the current market, only about 30% of market price. However, it was reset to market price on 1/1/2017.
- The GAO did a report strongly supportive innovation for new technology in the DME benefit. CMS's reaction was lukewarm or less. Here.
- CMS rejected a special new code for artificial pancreas (e.g. very smart insulin pumps) in 2014, but is reconsidering now, with a decision expected in November 2017.