Payments to Suppliers for Diabetic Test Strips (A-09-15-02001) iii . Frequency Guidelines for Blood Glucose Testing - April 2009; Certified Asthma and Diabetes Educators - March 2009; Ambulatory Care Payment Reform - February 2009; Certified Asthma and Diabetes Educators - December 2008; Diabetes and Asthma self-management training soon offered to Medicaid beneficiaries - October 2008; Diabetes and Asthma . Response: We disagree with the commenters that utilization assumptions for equipment should be revisited as part of the public health emergency. Advanced Diabetes Supply is a nationally accredited pharmacy that specializes in diabetes testing supplies. Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips. Commenters stated that any modifications to the equipment utilization during the public health emergency also should not be subject to budget neutrality. Diabetic equipment and supplies including blood glucose meters, test strips, syringes, and lancets. IEHP maintains Policies and Procedures that are shared with Providers to comply with State, Federal regulations and contractual requirements. Provider Manuals. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. Insulin pumps. Medica's Cost plans will The following categories of consumable medical supplies may be eligible for coverage according to federal or state mandates, or current industry standards: Diabetes supplies, including alcohol wipes. The products and product categories listed below must be billed to Medicare before being billed to . Service Resource(s) Last Reviewed / Approved; Asthma: 2007 National Heart, Lung, and Blood Institute (NIH) EPR-3 Guidelines for the Diagnosis and Management of Asthma (includes: 2008 edits to the 2007 guideline): Last reviewed 8/2021: Back Pain: 2017 American College of Physicians (ACP) Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline Last Revised Date: September 8, 2021. According to Jeffrey B. Halter, MD, a professor of internal medicine and director of the Geriatric . 3. Their purpose is to help you provide A study funded by the American Diabetes Association (ADA) found that "diabetes is rarely a focus of care for patients with diabetes when they require hospitalization for other conditions."1 The diagnosis of diabetes may not even be included in the hospital records of people who have diabetes. The treating participating physician or a qualified non-physician practitioner orders the services; B. Medicare covers in-office laboratory services when: A. American Diabetes Association guidelines state that individuals using multiple injections of insulin or on insulin pump therapy should test their blood glucose levels 3 or more times per day. Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories. DME may be rented, purchased or rented-to-purchase. Our FAQs answer key questions about . Pharmacy Services iv Library Reference Number: PROMOD00042 Published: August 24, 2021 Policies and procedures as of June 1, 2021 Version: 6.0 EmblemHealth only covers blood glucose meters and testing supplies for Abbott Diabetes Care products. The full list of Medical Policies and Clinical Utilization Management (UM) Guidelines are publicly available on the Medical Policy and Clinical UM Guideline subsidiary website. Medicare coverage of a CGM system supply allowance is available where a beneficiary uses a Clinical Utilization Management Guidelines . A patient who is a non-insulin controlled diabetic may receive 100 test strips and lancets every 3 months or 1 per day Modifier code KS Specified required documentation on file HCPCS Codes A4253 test strips 1 unit=50 test strips A4259 lancets 1 unit=100 lancets 2. Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service . Medicare covers some medical supplies. In the December 30, 2015 Federal Register, we published final rule titled "Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, and Supplies" (80 FR 81674), in accordance with section 1834(a)(15) of the Act, we established the Master List of Items Frequently Subject to Unnecessary Utilization . Comment #11: . Patients who need a change in their testing frequency or the type of meter or supplies used will need a new prescription. ordered a frequency of testing that exceeds the utilization guidelines and has documented the specific reason for the additional testing in the medical record (e.g., new onset of insulin dependent diabetes). the pharmacy whenever possible for diabetic supplies as it is much more cost effective* Diabetic Meters: Accu-Chek blood glucose meters and testing supplies are on Medica's formulary as the preferred option. 2022 Medicare Cost plans continue to focus on encouraging early detection and preventive care, resulting in benefit changes. When administered via a pump 5. When filled with a prescription at a pharmacy, the current preferred options are the FreeStyle family and Precision Xtra. Since the rollout of the DMEPOS competitive bidding program (CBP) in July, 2008, there has been confusion over what constitutes delivery and set-up of specific DMEPOS items. This requirement was an unnecessary barrier for Medicare beneficiaries, delaying access to this effective technology for individuals with diabetes. To refer a patient for care or disease management, please call the Medical Management Department: USFHP: 1-800-678-7347 ( 711 for TTY users). Medicare requires an explanation for testing more frequently than 1x day non-insulin or 3x day insulin treated; therefore, I confirm that I have evaluated this patient within the last six (6) months to assess their diabetes control and have noted below the reason(s) for high testing frequency.. Medicare Advantage: 1-844-282-3026 ( 711 for TTY users). The Medicare Hospital Insurance (HI) trust fund is projected to be depleted in 2026. If PAAD beneficiaries have health insurance coverage, such as Medicare Part B that pays for diabetic testing supplies a pharmacy must bill that insurance plan. PAAD will not pay for them. Services are medically necessary; and This means a standard claim for a patient's monthly (or three-month) allotment of these supplies would be two units of A4253 blood glucose test or reagent strips for home blood glucose monitor, per 50 strips and 1 unit of A4259 Lancets, per box of 100. Authorize CVS pharmacy to bill medicare for payment and serves as a medical release authorization Medicare standard utilization guidelines for diabetic testing supplies are as follow. All diabetic test strips are limited to 150 test strips per 30 days Glucometers are limited to 1 glucometer per 12 months Requests for Non-Formulary Diabetic Supplies require documentation of one of the following: A. beneficiary. If you are approved for an insulin pump, Part B also may cover the insulin used in the pump. Medicare Advantage claim processing and payments will be in accordance with the CMS guidelines.5 II. Utilization management practices Member Education Paramount actively reaches out to members on the following initiatives: Colorectal cancer screenings: Fit Kit information for patients who are due for a colonoscopy Diabetes testing: Annual mailing to members who have missed diabetes testing Medicare will consider coverage for the diabetic testing regimen as outlined in the Local Coverage Determination (LCD): For your patients that require additional testing per day, or the quantities of supplies ordered exceed Medicare's standard utilization parameters, there are some additional documentation requirements that must be met. Overview . Glucose control solutions for checking the accuracy of testing equipment and test strips. This Coverage Policy addresses various types of diabetic equipment and supplies, including continuous glucose Suppliers may use the date of delivery as the DOS on the claim. A PAAD beneficiary must be a New Jersey resident; From 1980 to 2004, the number of people aged 65 or older with diagnosed diabetes increased from 2.3 million to 5.8 million. WHAT WE RECOMMEND . physical examination, results of pertinent diagnostic tests or procedures. If PAAD beneficiaries have health insurance coverage, such as Medicare Part B that pays for diabetic testing supplies a pharmacy must bill that insurance plan. Durable Medical Equipment and Home Care Services All fully-insured HMO, HMO-POS, EPO, PPO, Medicare Advantage, and MVP Medicaid plans. diabetes. If the individual is regularly using quantities of supplies that exceed the usual utilization guidelines, new documentation must be present at least every six months. The treating physician has seen the member, evaluated their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, and has documented in the member's medical record the specific reason for the additional materials for that particular member; and Durable Medical Equipment, Prosthetics , Orthotics, and Supplies Procedure Codes and Coverage Guidelines Version 2022 (6/1/2022) 4 L3520F7 #Orthopedic shoe addition, insole, felt covered with leather L3530F7 #Orthopedic shoe addition, sole, half L3550F7 #Orthopedic shoe addition, toe tap standard L3560F7 #Orthopedic shoe addition, toe tap, horseshoe . $27B Reduced job productivity while at work. Diabetes Technol Ther. Home glucose monitors and Diabetic Testing Supplies (DTS) are covered by Medicare for persons with a diagnosis of diabetes, when certain criteria are met. Medicare Part B (Medical Insurance) covers glucose laboratory test screenings (with or without a carbohydrate challenge) if your doctor determines you're at risk for developing diabetes. Diabetic Supplies. Choose from a variety of high quality, accurate glucose meters. Care Management Requirements Medical Policy and Clinical UM Guideline subsidiary website. I, the undersigned, certify that the above prescribed supplies/equipment are medically necessary for . ========= IMAGE INFOPANEL. 2. Comment #10: . Coverage of services is subject to the terms, conditions, limitations of a member's policy and applicable state and federal law. Allowable NDCs for Diabetic Supply Billing - Effective 8/1/2011 For billing guidelines and examples: NDC Code Labeler Name Label Name Desc 00193144001 BAYER HEALTHCARE BREEZE 2 METER 00193145001 BAYER HEALTHCARE BREEZE 2 METER 00193146550 BAYER HEALTHCARE BREEZE 2 DISC TEST STRIP 00193146621 BAYER HEALTHCARE BREEZE 2 DISC TEST STRIP Medical Records Medical records verify that the beneficiary has diabetes which is being treated by a qualified practitioner. OPTUMRx DIABETES MANAGEMENT PROGRAM 3 Diabetes in the workplace Impact to employers $2B Reduced productivity for those not in the labor force. medicare standard utilization guidelines for diabetic testing supplies are as follow -for insulin dependent, max testing 3x a day -for non-insulin dependent, max 1x a day when is insulin covered by medicare part B when administered via a pump medicare part D and Medicare part B may be billed for the same item false Part 2 - Medical Supplies Page updated: April 2022 . Diabetic Supplies. I, the undersigned, certify that the above prescribed supplies/equipment are medically necessary for . Medicare considers 50 test strips as one unit and 100 lancets as one unit. Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines the health plan has adopted. coverage of CPT Code 95924 is best explained under Utilization Guidelines. Factors that go into the practitioner's decision making process for how often a person with diabetes should test their . 2013; 15(4):302-307. The quantity of glucose testing supplies that are covered depends on the usual medical needs of the diabetic patient Prior authorization is available for test strips, lancets, and other diabetic supplies if a member Coverage is subject to the terms and conditions of your policy and applicable state and federal law. Medicare glucose monitors and test strips For Medicare members only , Fallon Health reviews Medicare glucose monitor and test strip requests. Health Insurance Exchange: 1-844-282-3025 ( 711 for TTY users). A4256. Medicare coverage of a CGM supply allowance is available where a beneficiary uses a durable CGM receiver to display their glucose data and also transmits that data to a caregiver through a smart phone or other non-DME receiver. PAAD does not pay for diabetic testing supplies (e.g., test strips and lancets). Medicare Covered Services . Abstract. You generally pay 20% plus any applicable deductible. Medicaid reimburses for durable medical equipment (DME) and medical supplies appropriate for use in the recipient's home. All other plans: Fax a completed PARF* to 1-800-376-6373. If you meet certain medical conditions and your doctor believes an external insulin pump is medically necessary to treat your diabetes, Medicare may cover 80% of the allowable charges for the pump. Surgical wound care supplies, including gauze pads, wound cleansers, and compression bandages. Diabetic test strips and lancets b. Insulin syringes c. Ostomy supplies d. . For members with a hematocrit level that is either chronically less than 30% OR greater than 55%* COORDINATION OF CARE A. Self-insured ASO and MVP/CIGNA affiliated plans vary by plan type. Signatures on medical records meet CMS Signature Requirements Contact Information. While we agree that many services had a reduced . PREFERRED BRANDS Blood glucose meters and test strips for Medicare Advantage members must be a preferred brand product for coverage, with no coinsurance, copayment, or deductible. PAAD does not pay for diabetic testing supplies (e.g., test strips and lancets). A4258. Effective Date: January 1, 2012. $38B Due to disease-related disability and inability to work. complex insulin therapy regimens. Their purpose is to October 12, 2021: Effective 1/1/22, updated criteria to remove blood glucose testing requirement.