Article Detail - JA DME

Posted March 15, 2013

Medicare receives numerous claims for home blood glucose monitor strips and lancets. Many of these claims are for a higher than usual numbers of supplies. The Glucose Monitors local coverage determination has special coverage requirements for glucose supplies at all levels of utilization. The general coverage requirements in the policy state:

To be eligible for coverage of home blood glucose monitors and related accessories and supplies, the beneficiary must meet both of the following basic criteria (1) – (2):

1. The beneficiary has diabetes (ICD-9 codes 249.00-250.93); and

2. The beneficiary's physician has concluded that the beneficiary (or the beneficiary's caregiver) has sufficient training using the particular device prescribed as evidenced by providing a prescription for the appropriate supplies and frequency of blood glucose testing.

The specific policy requirements for supplies state:

The quantity of test strips (A4253) and lancets (A4259) that are covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. Coverage of testing supplies is based on the following guidelines:

Usual Utilization

• For a beneficiary who is not currently being treated with insulin injections, up to 100 test strips and up to100 lancets every 3 months are covered if the basic coverage criteria (1) - (2) (above) are met.

• For a beneficiary who is currently being treated with insulin injections, up to 300 test strips and up to 300 lancets every 3 months are covered if basic coverage criteria (1) - (2) (above) are met.

High Utilization

• For a beneficiary who is not currently being treated with insulin injections, more than 100 test strips and more than 100 lancets every 3 months are covered if criteria (a) – (c) below are met.

• For a beneficiary who is currently being treated with insulin injections, more than 300 test strips and more than 300 lancets every 3 months are covered if criteria (a) – (c) below are met.

a. Basic coverage criteria (1) - (2) listed above for all home glucose monitors and related accessories and supplies are met; and,

b. The treating physician has seen the beneficiary, 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 beneficiary's medical record the specific reason for the additional materials for that particular beneficiary; and,

c. If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician's records (e.g., a specific narrative statement that adequately documents the frequency at which the beneficiary is actually testing or a copy of the beneficiary's log) that the beneficiary is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the beneficiary is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.

If neither basic coverage criterion (1) nor (2) are met, all testing supplies will be denied as not reasonable and necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria (a) – (c) are not met, the amount in excess will be denied as not reasonable and necessary.

DMEPOS suppliers who provide glucose supplies are reminded that the requirements set out in the local coverage determination must be supported by information from the medical record. While suppliers are not required to obtain this information in advance of claim submission, in the event of an audit this information must be available upon request.

The information in the medical record must document the diagnosis of diabetes, the nature of treatment (non-insulin treated or insulin treated), the quantity of supplies, as well as the special requirements outlined above.

Suppliers are reminded that in addition to the medical record information required, a prescription (detailed written order), refill monitoring and proof of delivery documentation are required.

Refer to the Glucose Monitors Local Coverage Determination, and the related Policy Article for additional information.

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