medicare standard utilization guidelines for diabetic testing supplies

Response: We disagree with the commenters that utilization assumptions for equipment should be revisited as part of the public health emergency. According to Jeffrey B. Halter, MD, a professor of internal medicine and director of the Geriatric . Part 2 - Medical Supplies Page updated: April 2022 . 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. Medica's Cost plans will Medicare Advantage: 1-844-282-3026 ( 711 for TTY users). A4310 The prevalence of diabetes in the U.S. Medicare population is growing at an alarming rate. Unless an exception request is approved, test strips are limited to 200 strips per 30 days, and other test strips and meters are . 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.. This policy outlines the quantity of supplies necessary for those patients . 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. You may be eligible for up to 2 screenings each year. Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories. Blood Ketone test or reagent strip, each. 2. Last Updated on May 22, 2021. ========= IMAGE INFOPANEL. 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. WHAT WE RECOMMEND . 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. CGS's Medicare Payments to Suppliers for Diabetic Test Strips (A-09-14-02015) ii suppliers on Medicare requirements and billing 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. While we agree that many services had a reduced . Clinical Utilization Management Guidelines . A4253. IEHP maintains Policies and Procedures that are shared with Providers to comply with State, Federal regulations and contractual requirements. 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. 2. Comment #11: . beneficiary. Changes may occur after printing. Official Medicare Program To refer a patient for care or disease management, please call the Medical Management Department: USFHP: 1-800-678-7347 ( 711 for TTY users). An edit is programming within the standard claim processing system that selects certain claims; evaluates or compares information Diabetic Supplies. We abide by Medicare's standard utilization guidelines for diabetic testing supplies (DTS) dispensed to Medicare Part B patients in order to meet Medicare's medical necessity requirements: once per. 1. 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. A4259. Medicare Advantage claim processing and payments will be in accordance with the CMS guidelines.5 II. Services are medically necessary; and Self-monitoring of blood glucose (SMBG) is a critical component of diabetes care among individuals treated with insulin (1,2).The American Diabetes Association recommends that all insulin-treated individuals should perform SMBG according to the needs of their insulin regimen ().For individuals treated with intensive insulin regimens, SMBG should be performed at least prior to meals/snacks and . When administered via a pump Payments to Suppliers for Diabetic Test Strips (A-09-15-02001) iii . 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. 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. OPTUMRx DIABETES MANAGEMENT PROGRAM 3 Diabetes in the workplace Impact to employers $2B Reduced productivity for those not in the labor force. Please fax requests to 1-508-791-5101 or call 508-368-9825, option 5, option 2. See pages 10-13. Medicare will consider coverage of a glucose monitor and related supplies when your patient's medical record shows they have diabetes and you have determined he/she or a caregiver is sufficiently trained to use the prescribed device appropriately. Medicare plans: Fax a completed PARF* to 1-800-401-0915 . Source: CMS IOM Pub. Urine test or reagent strips or tablets (100 tablets or strips) A4252. Commenters stated that any modifications to the equipment utilization during the public health emergency also should not be subject to budget neutrality. If you are approved for an insulin pump, Part B also may cover the insulin used in the pump. PAAD does not pay for diabetic testing supplies (e.g., test strips and lancets). guidelines from the royal australian college of general practitioners (racgp, 2007) explained that measurement of gad can be of particular use in diagnosing late onset autoimmune diabetes in adults (lada), a form of late onset diabetes that is autoimmune and requires treatment with insulin within a relatively short period of time after diagnosis Comment #10: . Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips. NGS's Medicare . Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. First, the test was the first application of VBID in a population aged 65 and older. $327 billion: total cost of diagnosed diabetes in 2017. Overview . Many Cost plans will offer $0 copays on diabetic testing supplies, Medicare-covered glaucoma and diabetic retinopathy screenings as well as mental health office visits and kidney disease education. Contact Information. Medicare considers 50 test strips as one unit and 100 lancets as one unit. $3B Absenteeism $20B Lost productivity due to early death. DME may be rented, purchased or rented-to-purchase. Medicare covers some medical supplies. 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. Diabetic equipment and supplies including blood glucose meters, test strips, syringes, and lancets. Carlsson BM, Attvall S, Clements M, et al. Mobility aids including canes, crutches, walkers, and wheelchairs. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. 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 . Medicare Requirements for Diabetic Strips Requirements for the Written order from the doctor 1) Patient Name 2) Specific frequency of testing ( NO MORE PRN OR AS NEEDED ORDERS 3) Length of need for test strips 4) Doctor's name and signature 5) Start date of order if different than signed date Maximum Glucose Testing Supplies Allowances Medicare covers some medical supplies. the specific quantity of supplies that exceeds the usual utilization amounts described above; and, c. Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual utilization amounts, the treating practitioner must verify adherence to the high utilization testing regimen. Insulin pumps may be approved for patients under age 21 when certain conditions are met. Normal, low and high calibrator solution/chips. When Medicare covers an item and the recipient is eligible for Medicare, providers bill Medicare before billing Medi-Cal. Only drugs approved by the Food and Drug Administration are covered. Part 2 - Medical Supplies Page updated: April 2022 . J. Pharmacy Access Standards K. Medication Therapy Management Program L. Insulin Administration Devices and Diabetes Testing Supplies M. Member Request for Pharmacy Reimbursement N. Pharmacy Disease Therapy Management Program O. Pharmacy Credentialing and Re-Credentialing Attachments 12. Medicare covers certain supplies if you have diabetes and Part B, including: Blood sugar self-testing equipment & supplies. This Coverage Policy addresses various types of diabetic equipment and supplies, including continuous glucose Diabetes Care Volume 42, Supplement 1, January 2019. According to the Centers for Medicare and Medicaid (CMS), 32% of Medicare spending is attributed to the diabetes population. Medical Records Medical records verify that the beneficiary has diabetes which is being treated by a qualified practitioner. The full list of Medical Policies and Clinical Utilization Management (UM) Guidelines are publicly available on the . 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 diabetes. Learn More. Most diabetic supplies, such as glucose testing meters, test strips and other related supplies are a benefit with a prescription from a physician, physician assistant or nurse practitioner. Their purpose is to help you provide Members have access to one of the listed Accu-Chek blood glucose meters at no extra cost: Members with Medicare, diabetic testing supplies "Medicare Coverage of Durable Medical Equipment & Other Devices" isn't a legal document. -For insulin dependent, max testing 3x a day -For non-insulin dependent, max 1x a day When is insulin covered by Medicare Part B? In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. This requirement was an unnecessary barrier for Medicare beneficiaries, delaying access to this effective technology for individuals with diabetes. 3. 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 coverage of CPT Code 95924 is best explained under Utilization Guidelines. Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service . Medicare Utilization Guidelines Sign/Date and . I, the undersigned, certify that the above prescribed supplies/equipment are medically necessary for . 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. TTY users should call 1-877-486-2048. When Medicare covers an item and the recipient is eligible for Medicare, providers bill Medicare before billing Medi-Cal. See page 13. Medicare coverage of a CGM system supply allowance is available where a beneficiary uses a Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. Medical Policy and Clinical UM Guideline subsidiary website. I, the undersigned, certify that the above prescribed supplies/equipment are medically necessary for . In some instances, beneficiaries have experienced delays in obtaining the necessary DMEPOS items. Suppliers may use the date of delivery as the DOS on the claim. 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. Medicare Covered Services . The products and product categories listed below must be billed to Medicare before being billed to . Clinical practice guidelines for chronic conditions (ADHD, asthma, COPD, depression, diabetes, heart failure, hypertension, lipid management, nicotine dependence) Security Health Plan has adopted the Institute of Clinical Systems Improvement (ICSI) guidelines to ensure our members receiving high-quality care. C. Billing Requirements . UniCare Health Plan of West Virginia, Inc. Clinical Utilization Management Guidelines Page 6 of 8 Clinical UM Guideline # Clinical UM Guideline title New item CG-MED-88 Preimplantation Genetic Diagnosis Testing CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces CG-OR-PR-03 Custom-made Knee Braces CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics) Choose from a variety of high quality, accurate glucose meters. From 1980 to 2004, the number of people aged 65 or older with diagnosed diabetes increased from 2.3 million to 5.8 million. $38B Due to disease-related disability and inability to work. 4. American Diabetes Association. Recipients must have insulin-dependent diabetes mellitus (IDDM, Type 1), must have been in a program of multiple daily injections for at least six months, and must have documentation of glucose self-testing at least four times a day in the three months prior to use of a insulin pump. Standards of Medical Care in Diabetes - 2019. Beginning on July 18, 2021, Medicare will permanently eliminate the requirement of the four-time-daily fingerstick in order to qualify for coverage of a continuous glucose monitor (CGM). 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). Insulin pumps. Factors that go into the practitioner's decision making process for how often a person with diabetes should test their . 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.. . Advanced Diabetes Supply is a nationally accredited pharmacy that specializes in diabetes testing supplies. October 12, 2021: Effective 1/1/22, updated criteria to remove blood glucose testing requirement. 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. To confirm benefit coverage or to request a copy of a clinical guideline used to support medical necessity decisions, please contact Member or Provider Services: 855-672-2755 for Oscar Plans and 855-672-2789 for Cigna+Oscar Plans. EmblemHealth only covers blood glucose meters and testing supplies for Abbott Diabetes Care products. Diabetic supplies are available for insulin, and non-insulin dependent members. 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 Medicare Part B covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. 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. Effective Date: January 1, 2012. 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 Surgical wound care supplies, including gauze pads, wound cleansers, and compression bandages. 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 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 5. Lancets, per box of 100. Medicare covers in-office laboratory services when: A. 2. The Medicare Hospital Insurance (HI) trust fund is projected to be depleted in 2026. Durable Medical Equipment and Home Care Services All fully-insured HMO, HMO-POS, EPO, PPO, Medicare Advantage, and MVP Medicaid plans. When filled with a prescription at a pharmacy, the current preferred options are the FreeStyle family and Precision Xtra. 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 Glucose control solutions for checking the accuracy of testing equipment and test strips. A4258. Diabetic test strips and lancets b. Insulin syringes c. Ostomy supplies d. . Quartz Medicare Advantage (QMA) members: Preferred test strips are listed on the QMA formulary. Medicare Covered Services . 3. 100-03 Medicare National Coverage Determination, Chapter 1, section 40.2 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. For members with a hematocrit level that is either chronically less than 30% OR greater than 55%* Overview This policy supports medical necessity review for Glucose Test Strips. Coverage of services is subject to the terms, conditions, limitations of a member's policy and applicable state and federal law. The products and product categories listed below must be billed to Medicare before being billed to . Signatures on medical records meet CMS Signature Requirements 2 for Diabetes Supplies T his section provides information about Part B (Medical Insurance) and its coverage of diabetes supplies. Therapeutic shoes or inserts . You generally pay 20% plus any applicable deductible. A PAAD beneficiary must be a New Jersey resident; All other plans: Fax a completed PARF* to 1-800-376-6373. Spring-powered device for lancet, each. 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. physical examination, results of pertinent diagnostic tests or procedures. Health Insurance Exchange: 1-844-282-3025 ( 711 for TTY users). Care Management Requirements 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. Provider Manuals. 2022 Medicare Cost plans continue to focus on encouraging early detection and preventive care, resulting in benefit changes. Abstract. The treating participating physician or a qualified non-physician practitioner orders the services; B. Blood Glucose Meters and Testing Supplies - EmblemHealth Medicare PPO and Medicare Prescription Drug Plan Members. Criteria for A1C not being met was updated to remove requirement of education and adherence to blood glucose testing. C. Ongoing documentation of the care and management of the patient's diabetic control; D. Ongoing documentation that the patient is testing at home at the frequency ordered; E. Documentation that the patient is testing at a frequency that exceeds utilization guidelines for insulin or noninsulin dependent patients must meet the following criteria: Insulin pump-long-term effects on glycemic control: an observational study at 10 diabetes clinics in Sweden. Also updated insulin requirement from multiple daily insulin injections to multiple daily insulin administrations. PAAD will not pay for them. Medicaid reimburses for durable medical equipment (DME) and medical supplies appropriate for use in the recipient's home. Our FAQs answer key questions about . complex insulin therapy regimens. 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 Purpose: This policy provides guidelines for reimbursement of diabetic supply codes when the utilization of these supplies is at a frequency over the usage listed by supply code. Insufficient documentation is the top reason for improper payments for glucose monitors, which include DTS. Diabetic Supplies. The projected deficit amounts to $517 billion between 2026 and 2031. Physician has seen and evaluated the beneficiary's diabetes within six months of ordering quantities of supplies above the normal utilization and has documented the specific reason for the additional supplies; and Medical records document the frequency of actual testing by the beneficiary. The diabetic supplies covered by Blue Cross Blue Shield PPO may include: test strips, lancets, control solution, lancing devices and more. Medicare Program at the time this booklet was printed. Coverage is subject to the terms and conditions of your policy and applicable state and federal law. LOINC Codes: The following information may be required documentation to support medical necessity: physician history Diabetic supplies MUST be billed as DMEPOS. COORDINATION OF CARE 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. Medical Necessity Criteria Coverage for glucose test strips varies across plans and may require the use of preferred products. coded appropriately according to industry standard coding guidelines (including but not limited . Diabetes Technol Ther. High Utilization for Over Quantity Diabetic supplies limits: Limits for supplies are guided by state and federal guidelines. The Centers for Medicare & Medicaid Services (CMS) is charged with the implementation and oversight of the DMEPOS program. . All of this is considered standard medical record documentation. Pharmacy Services iv Library Reference Number: PROMOD00042 Published: August 24, 2021 Policies and procedures as of June 1, 2021 Version: 6.0 We recommend that NGS implement a system edit to identify for review claims submitted by Part B covers these screenings if you have any of these risk factors: High blood pressure (hypertension) Inpatient hospital services; PAAD will not pay for them. PAAD does not pay for diabetic testing supplies (e.g., test strips and lancets).

medicare standard utilization guidelines for diabetic testing supplies