Does E0784 require prior authorization?

Yes, E0784 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

`E0784`, External ambulatory infusion pump, insulin

HCPCS/CPT

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

A Standard Written Order (SWO) must be communicated to the supplier before claim submission and a signed Written Order Prior to Delivery (WOPD) must be received before delivery of DMEPOS base items that require WOPD.
Proof of delivery (POD) documentation must be maintained by the supplier and be made available to the Medicare contractor upon request; claims without appropriate POD will be denied.
For insulin pump coverage, document C-peptide testing (meeting specified thresholds), beta cell autoantibody positivity, comprehensive diabetes education completion, prior multiple daily injection regimen (≥3 injections/day for ≥6 months) with self-adjustments, and documented glucose self-testing frequency (average ≥4 times/day for 2 months prior to initiation or ≥4 times/day during the month prior to Medicare enrollment if previously on a pump).

External infusion pumps (HCPCS E0779, E0780, E0781, E0791) are covered for administration of deferoxamine for treatment of chronic iron overload.
External infusion pumps are covered for administration of anticancer chemotherapy for unresectable primary hepatocellular carcinoma or unresectable colorectal cancer or when the beneficiary refuses surgical excision of the tumor.
External infusion pumps are covered for administration of morphine for intractable cancer pain.
Continuous subcutaneous insulin infusion (pump E0784) is covered for diabetes mellitus when the beneficiary meets either criterion A (C-peptide/autoantibody evidence of insulin deficiency) or B (prior successful insulin pump use before Medicare enrollment) and either criterion C (prior multiple daily injection program with documented deficiencies) or D (prior pump use with documented glucose testing).
External ambulatory insulin infusion pumps that incorporate non-adjunctive CGM dose adjustment are described by HCPCS combination E0784 + E2103 and are covered only if the beneficiary meets all insulin pump criteria and all CGM criteria in Glucose Monitors LCD L33822.
External ambulatory insulin infusion pumps with integrated adjunctive CGM receiver functionality are described by HCPCS combination E0784 + E2102 and are covered only if the beneficiary meets all insulin pump criteria and all CGM criteria in Glucose Monitors LCD L33822 (claims on/after 4/1/2022).

ANTHEM-CG-DME-42, Continuous Glucose Monitoring Devices

ANTHEM-CG-DME-51, External Insulin Pumps

ANTHEM-CG-DME-50, Automated Insulin Delivery Systems

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

L33794, External Infusion Pumps

Ask Backwork about documentation requirements, denial risks, or coverage in your state.