Reimbursement of Continuous Subcutaneous’ Insulin Infusion (CSII) Pump Therapy’ under CGHS/CS(MA) Rules, 1944 – Guidelines

Reimbursement of Continuous Subcutaneous’ Insulin Infusion (CSII) Pump Therapy’ under CGHS/CS(MA) Rules, 1944 – Guidelines: MoHFW OM dated 16.05.2023

File No: S.11030/120/2022-EHS
Government of India
Ministry of Health & Family Welfare
EHS Section
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Nirman Bhawan, New Delhi
Dated 16.05.2023

OFFICE MEMORANDUM

Subject: Guidelines regarding reimbursement of Continuous Subcutaneous’ Insulin Infusion (CSII) Pump Therapy’ under CGHS/CS(MA) Rules, 1944 – regarding

The undersigned is directed to refer to representations seeking permission/ex-post facto approval for use /reimbursement of Insulin Pump under CGHS/CS(MA) Rules. This matter has been examined by a Committee of Experts, of the Directorate General of Health Services, in the field. Based on the recommendations of the Expert Committee; this Ministry has framed following guidelines for use/reimbursement of Cost of Insulin Pump:

A. ELIGIBLE PATIENTS

The following criteria must be met:

1. Patients with Type -I Diabetes
2. Duration of diabetes greater than 2 years
3. The child and family have received adequate diabetes education at a centre experienced in taking care children with Type-l, Diabetes Mellitus.
4. Despite multiple daily doses of Insulin and proper adherence to diet in last 6 months, HbAIC level is not below 8.5 %.
5. Recurrent and unexplained hypoglycemia on multiple doses of insulin despite proper adherence to diet in last 6 months.

B. PREREQUISITES

Should be on multiple daily doses of Insulin (basal bonus) therapy for a minimum of 6 moths. During the period there should be

1. At least 2 HBAl1c readings over these 6 months
2. Strict Self- monitoring Blood Glucose (SMBG) with minimum 4 readings or be on Continuous Glucose Monitoring System(CGS)
3. Should have a concept of carbo-counting (Counting number of grams of Carbohydrate in a meal) and its application in diabetes management, as certified by the treating pediatric endocrinologist / endocrinologist/ diabetes clinic specialist
4. The family can understand pump usage, to calculate bolus and basal insulin doses as required, and has demonstrated motivation to follow guidelines related to SMBG monitoring and diet.
5. Regular follow-up with a pediatric endocrinologist / endocrinologist/ diabetes clinic specialist
6. No history of psychiatric illness in patient.

C. APPROVAL

A committee under the chairpersonship of Addl. Director General with 2-3 pediatric endocrinologists / endocrinologists/ diabetes clinic specialists as members will examine each request, on case to case basis, as per the guidelines. The cases, which may not be covered under these guidelines, to be taken up, on case to case basis.

• In case of CGHS beneficiaries, Additional Director (R&H) / Addl DDG(HQ) , CGHS Shall be Member Secretary.
• In case of CS(MA) beneficiaries, Chief Medical Officer of MG Section shall be the Member Secretary.
• The concerned Ministry / Department of the serving central Government employees in CGHS covered cities shall forward the requests for permission to the Additional Director, CGHS of city concerned.
• Pensioner shall submit their request to their parent CGHS Wellness Centre to which they are registered and that request will be further sent to Additional Director, CGHS of the city concerned, for consideration.
• In case of CS(MA) beneficiaries the concerned Ministry / Department of the serving central Government employees shall forward the requests for permission to the Under Secretary , EHS Section , Ministry of Health & Family Welfare.

D. VALIDITY

1. Initial approval shall be for one year. Both basic as well as sensor augmented Insulin Pumps may be considered as prescribed by treating endocrinologist.
2. Re-approval will be done only if the following criteria are met:
   1. Regular follow-up (at 3-month intervals at least) during the past one year.
   2. Regular self monitoring of blood glucose (SMBG).
   3. HbAlc test every 3 months over past one year with at least two HbAl1c values below 8.5%.
3. If re-approval is not granted as above, the patients can re-apply after 6 months, if he/she meets these criteria – HbAlc less than 8.5% at least one in last 6 months.

E. CEILING RATE FOR CONTINUOUS SUBCUTANEOUS INSULIN INFUSION (CSII ) PUMP THERAPY UNDER CGHS/CS(MA) RULES

• Ceiling rate for basic version of Insulin Pump are fixed at 2 Lakhs.
• Ceiling rate for a sensor-augmented Insulin Pump are fixed at Rs. 3.0 Lakhs.
• In addition, the monthly cost for the consumables is fixed at Rs 5,000/- (reservoir, infusion set and Insulin).

2. These guidelines issues with the approval of competent authority and concurrence of IFD vide CD No. 385 dated 15.05.2023.

(Hemlata Singh)
Signed by
Hemlata Singh
Date: 16-05-2023 11:25:17
Under Secretary to the Government of India
Tel. No. 011-23061778

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