Guidelines for Reimbursement of Continuous Subcutaneous Insulin Infusion (CSII) Pump Therapy Under CGHS/CS(MA) Rules, 1944

Comprehensive Guidelines for Reimbursement of Insulin Pump Therapy under CGHS/CS(MA) Rules

The Ministry of Health & Family Welfare has recently released updated guidelines regarding the reimbursement of Continuous Subcutaneous Insulin Infusion (CSII) Pump Therapy under the CGHS/CS(MA) Rules. These guidelines were formulated based on the recommendations of an Expert Committee from the Directorate General of Health Services. In this blog post, we will provide a detailed overview of the eligibility criteria, prerequisites, approval process, validity, and the ceiling rates for Insulin Pump Therapy.

Eligible Patients:

To be eligible for reimbursement, patients must meet the following criteria:

1. Type-I Diabetes: Patients diagnosed with Type-I Diabetes are eligible for consideration.

2. Duration of Diabetes: The duration of diabetes should be greater than 2 years.

3. Diabetes Education: The child and their family should have received adequate diabetes education at a specialized center experienced in caring for children with Type-I Diabetes Mellitus.

4. HbA1C Level: Despite proper adherence to diet and multiple daily doses of insulin, the HbA1C level should not be below 8.5% in the last 6 months.

5. Recurrent Hypoglycemia: Patients should experience recurrent and unexplained hypoglycemia, even with multiple doses of insulin and proper adherence to diet in the last 6 months.

Prerequisites:

Before considering reimbursement, the following prerequisites should be met:

1. Insulin Therapy: Patients should be on multiple daily doses of insulin (basal bonus) therapy for a minimum of 6 months.

2. Monitoring and Documentation: During this period, there should be at least 2 HbA1C readings, strict self-monitoring of blood glucose (SMBG) with a minimum of 4 readings, or utilization of a Continuous Glucose Monitoring System (CGS).

3. Diabetes Management Knowledge: Patients should have a concept of carbo-counting (counting the number of grams of carbohydrates in a meal) and its application in diabetes management, as certified by a treating pediatric endocrinologist, endocrinologist, or diabetes clinic specialist.

4. Pump Usage Understanding: The family should have the ability to understand pump usage, calculate bolus and basal insulin doses as required, and demonstrate motivation to follow guidelines related to SMBG monitoring and diet.

5. Regular Follow-Up: Patients should have regular follow-up with a pediatric endocrinologist, endocrinologist, or diabetes clinic specialist.

6. No Psychiatric Illness: There should be no history of psychiatric illness in the patient.

Approval Process:

The approval process involves a committee consisting of the following members:

- Chairperson: Additional Director General
- Members: 2-3 pediatric endocrinologists, endocrinologists, or diabetes clinic specialists

Each request will be examined on a case-by-case basis as per the guidelines. In case of CGHS beneficiaries, Additional Director (R&H) / Addl DDG(HQ), CGHS, will be the Member Secretary. For CS(MA) beneficiaries, the Chief Medical Officer of MG Section will act as the Member Secretary.

Requests for permission should be forwarded to the respective Additional Director, CGHS, or Under Secretary, EHS Section, Ministry of Health & Family Welfare.

Validity and Re-approval:

Initial approval for reimbursement will be granted for one year. Both basic and sensor-augmented versions of Insulin Pumps may be considered as prescribed by the treating endocrinologist. Re-approval will be subject to the following criteria:

1. Regular Follow-Up: Patients should have had regular follow-up (at least every 3 months) during the past year.

2. SMBG and HbA1

C Monitoring: Regular self-monitoring of blood glucose (SMBG) and HbA1c tests every 3 months should be conducted, with at least two HbA1C values below 8.5% during the past year.

3. Re-application: If re-approval is not granted, patients can re-apply after 6 months if they meet the criteria of having an HbA1C level less than 8.5% at least once in the last 6 months.

Ceiling Rates:

The ceiling rates for Continuous Subcutaneous Insulin Infusion (CSII) Pump Therapy under CGHS/CS(MA) Rules are as follows:

- Basic Insulin Pump: The ceiling rate is fixed at 2 Lakhs.
- Sensor-Augmented Insulin Pump: The ceiling rate is fixed at 3.0 Lakhs.
- Consumables: The monthly cost for consumables, including reservoir, infusion set, and insulin, is fixed at Rs 5,000.

Stay Connected With Us For All New Latest Updates

Through Our Telegram Channel

👇

https://t.me/DOP_Techshala