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Inotropic Therapy

Administration of dobutamine, milrinone and/or dopamine for patients with congestive heart failure and depressed cardiac function is covered in the home if a patient meets one of the two sets of criteria below:

Criteria set 1
1. Parenteral infusion in the home is reasonable and necessary.
2. An infusion pump is necessary to safely administer the drug.
3. The drug is administered by a prolonged infusion of at least 8 hours because of proven improved clinical efficacy.
4. The therapeutic regimen is proven or generally accepted to have significant advantages over intermittent bolus administration regimes or infusions lasting less than 8 hours.

Criteria set 2
1. Parenteral administration of the drug in the home is reasonable and necessary.
2. An infusion pump is necessary to safely administer the drug.
3. The drug is administered by intermittent infusion (each episode of infusion lasting less than 8 hours) which does not require the patient to return to the physician's office prior to the beginning of each infusion.
4. Systemic toxicity or adverse effects of the drug is unavoidable without infusing it at a strictly controlled rate as indicated in the Physicians Desk Reference, American Medical Associations drug Evaluations, or the U.S. Pharmacopeia Drug Information.

The patient must all of the following criteria to qualify for Inotropic coverage:

1. Dyspnea at rest is present despite treatment with maximum or near maximum tolerated doses of digoxin, a loop diuretic, and an angiotensin converting enzyme inhibitor or another vasodilator (e.g., hydralazine, or isosorbide dinitrate), used simultaneously (unless allergic or intolerant).
2. Doses are within the following ranges (lower doses will be covered only in part of a waning or tapering protocol from higher dose levels):
   1. Dobutamine 2.5 - 10 mcg/kg/min
   2. Milrinone 0.375 - 0.750 mcg/kg/min
   3. Dopamine < 2 mcg/kg/min
3. Invasive hemodynamic studies performed within 6 months prior to the initiation of home inotropic therapy show:
   1. cardiac index (CI) is less than or qual to 2.2 liters/min/meter squared and/or pulmonary wedge pressure (PCWP) is greater than or equal to 20 mm Hg before inotropic infusion on maximum medical management and
   2. At least a 20% increase in CI and/or at least a 20% decrease in PCWP during inotrope infusion at the dose initially prescribed for home infusion.
4. There has been an improvement in patient well-being, (less dyspnea, improved diuresis, improved renal function and/or reduction in weight) with the absence of dyspnea at rest at the time of discharge and the capability of outpatient evaluation by the prescribing physician at least monthly.
5. In the case of continuous infusion, there is documented deterioration in clinical status when the drug(s) is tapered or discontinued under observation in the hospital or

   In the case of intermittent infusions, there is documentation of repeated hospitalizations for congestive heart failure despite maximum medical management.

6. Any life threatening arrhythmia is controlled prior to hospital discharge and there is no need for routine electrocardiographic monitoring in the home.

1. The patient is maintained on the lowest practical dose and efforts to decrease the dose of the drug(s) or the frequency/duration of infusion are documented during the first 3 months of therapy.
2. The patient's cardiac symptoms, vital signs, weight, lab values, and response to therapy are routinely assessed and documented in the patient's medical record.

View and Print the Inotropic qualification checklist and data collection form^*

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