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November 12, 2026

LCD and Policy Article Revisions Summary for November 12, 2026

Joint DME MAC Publication

Outlined below are the principal changes to the DME MAC Local Coverage Determination (LCD) and Policy Article (PA) that have been revised and posted. The policy included is External Infusion Pumps. Please review the entire LCD and PA for complete information.

External Infusion Pumps

LCD

External Infusion Pumps LCD

Revision Effective Date: 10/01/2026

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

Revised: Information pertaining to the external infusion pumps with which an IV pole (E0776) is considered not reasonable and necessary, by adding "E0788" to the list of ambulatory infusion pump HCPCS codes

11/12/2026: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.

PA

External Infusion Pumps PA

Revision Effective Date: 10/01/2026

CODING GUIDELINES:

Revised: "An ambulatory infusion pump (E0781) is an electrical or battery-operated device, which is used to deliver solutions containing a parenteral drug under pressure at a regulated flow rate. It is small, portable, and designed to be carried by the beneficiary." to "An ambulatory infusion pump coded E0781 is an electrical or battery-operated device, which is used to deliver solutions containing a parenteral drug under pressure at a regulated flow rate. It is small, portable, and designed to be worn or carried by the beneficiary."
Revised: "A reusable mechanical infusion pump (E0779) is a device used to deliver solutions containing parenteral drugs under pressure at a constant flow rate determined by the tubing with which it is used." to "A reusable mechanical infusion pump coded E0779 is a device used to deliver solutions containing parenteral drugs under pressure at a constant flow rate determined by the tubing with which it is used."
Revised: "An ambulatory infusion pump (E0788) is an electrical or battery-operated device, approved by the FDA to be used with a specific drug (i.e., FDA-approved as a device-drug combination). It is used to deliver solutions containing a parenteral drug under pressure at a regulated flow rate. It is designed to be worn or carried by the beneficiary." to "An ambulatory infusion pump coded E0788 is an electrical or battery-operated device, approved by the FDA to be used with a specific drug (i.e., FDA-approved as a device-drug combination). It is used to deliver solutions containing a parenteral drug under pressure at a regulated flow rate. It is small, portable, and designed to be worn or carried by the beneficiary."
Added: "infusion sets" to items included in code A4222, as clarification
Revised: "Claims for codes A4221, A4222 and K0552 must only be used with a non-insulin external infusion pump (E0779, E0780, E0781, E0791 or K0455)." to "Codes A4221 and A4222 must only be used with a non-insulin external infusion pump coded E0779, E0780, E0781, E0791 or K0455." and to "Code K0552 must only be used with a non-insulin external infusion pump coded E0779, E0780, E0781, E0788, E0791, or K0455."
Revised: "Claims with dates of service on or after January 01, 2017 for codes A4221, A4222 and K0552 used with an external infusion pump HCPCS code E0784 are incorrectly coded." to "Claims with dates of service on or after January 01, 2017 for codes A4221 and A4222 used with an external infusion pump coded E0784 are incorrectly coded." and to "Claims with dates of service on or after January 01, 2017 for code K0552 used with an external infusion pump coded E0784 are incorrectly coded."
Revised: "Code A4228 includes all necessary supplies to maintain a specific device-drug combination, per week. This includes, but is not limited to, cassettes, syringe reservoirs or bags, diluting solutions, infusion sets, tubing and other administration supplies, port cap changes, compounding charges, and preparation charges." to "Code A4228 includes supplies to maintain a specific device-drug combination, per week. This includes the cassette or bag, diluting solutions, infusion sets, tubing and other administration supplies, port cap changes, compounding charges, and preparation charges. This code is not used for a syringe-type reservoir."
Added: "Code A4228 must only be used with a non-insulin external infusion pump coded E0788"
Revised: "Code K0552 describes a syringe-type reservoir that is used with the K0455, E0779, E0780, E0781 or E0791 when used to administer a drug utilizing a syringe-type reservoir." to "Code K0552 describes a syringe-type reservoir that is used with the pump to administer a drug utilizing a syringe-type reservoir."
Revised: "Code A4232 is invalid for submission to Medicare and should not be used for this purpose." to "Code A4232 is invalid for submission to Medicare and must not be used for this purpose.," as clarification
Added: "insulin" to items included in code A4224, as clarification
Revised: "Claims for codes A4224 and A4225 must only be used with insulin infusion pumps (E0784)." to "Codes A4224 and A4225 must only be used with an external insulin infusion pump (E0784)."
Revised: The table that describes HCPCS supply codes that are used with different types of external infusion pumps, by revising the information in the Associated Codes column within the row that contains E0788 in the Pump HCPCS Code column. The information in the Associated Codes column within the row was revised from "A4228" to "A4228***, K0522***"
Revised: The table that describes HCPCS supply codes that are used with different types of external infusion pumps, by revising the information in the Non-Associated Codes column within the row that contains E0788 in the Pump HCPCS Code column. The information in the Non-Associated Codes column within the row was revised from "A4221, A4222, A4224, A4225, K0552" to "A4221, A4222, A4224, A4225"
Revised: "*For E0779, E0780, E0781, E0791 and K0455 pumps, either A4222 and/or K0552 may be billed. Claims for K0552 (SUPPLIES FOR EXTERNAL NON-INSULIN DRUG INFUSION PUMP, SYRINGE TYPE CARTRIDGE, STERILE, EACH) are not separately payable if an infusion drug is pre-packaged and supplied in a syringe type cartridge." to "*For E0779, E0780, E0781, E0791 and K0455 pumps, HCPCS code(s) A4222 and/or K0552 may be billed. Claims for K0552 are not separately payable if an infusion drug is pre-packaged and supplied in a syringe type cartridge."
Revised: "**For E0784 pumps, either A4238 or A4239 may be billed if used in conjunction with an integrated adjunctive or non-adjunctive CGM, respectively." to "**For an E0784 pump, either A4238 or A4239 may be billed if used in conjunction with an integrated adjunctive or non-adjunctive CGM, respectively."
Added: "***For an E0788 pump, HCPCS code(s) A4228 and/or K0552 may be billed. Claims for K0552 are not separately payable if an infusion drug is pre-packaged and supplied in a syringe type cartridge."
Revised: "Do not use code J9999 - this code is not valid for claims billed to the DME MAC." to "Do not use code J9999.," as clarification

11/12/2026: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Note: The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.