Glucose Monitors (HCPCS A4253) Notification of Documentation Compliance Review

Noridian Jurisdiction A, DME MAC, Medical Review will be initiating a documentation compliance review of the following HCPCS code(s).


A documentation compliance review is a nonclinical, technical review verifying that submitted documentation meets payment requirements according to Local Coverage Determinations (LCD) for that DMEPOS item. This review is being initiated based on a high Comprehensive Error Rate Testing (CERT) error rate.

In order to evaluate compliance with Medicare coverage and coding rules, all suppliers billing Jurisdiction A for HCPCS codes listed above are subject to this review. Suppliers of the selected claims will receive an Additional Documentation Request (ADR) letter asking for the following specific information to determine if the item billed complies with the existing reasonable and necessary criteria.

  • Treating physician's dispensing and written order
  • Documentation to support refill requirements
  • If refill of quantities of supplies that exceed the utilization guidelines are dispensed, submit documentation to support the beneficiary is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed
  • Proof of delivery
  • The Advance Beneficiary Notice of Noncoverage (if applicable)
  • Any other supporting documentation

Failure to supply the above requested information within 45 days of the date of the letter will result in the claim being denied. Please fax or mail the requested documentation and a copy of the ADR letter. The ADR letter provided will also provide instruction for submitting documentation.

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Glucose Monitors Local Coverage Determination (LCD) L33822 and Policy Article A52464 on the Active LCDs webpage.

Additional information, educational opportunities and training tools related to this product category are available in Education & Outreach.

Information about prepay reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3


Last Updated Tue, 25 Feb 2020 16:21:57 +0000