Clinicians! Are You Ordering Glucose Monitors and Supplies For Your Patient - JA DME

November 9, 2018 - Revised July 2020

The Comprehensive Error Rate Testing (CERT) program has noted claim errors for glucose monitors. The following information is provided to assist you in reducing these types of errors.

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. (Reference: CMS publication 100-3, Section 40.2.)

Order Requirements

The Standard Written Order (SWO) for the glucose monitor and supplies must include the following:

• Patient name or Medicare Beneficiary Identifier (MBI)
• Order Date
• General description of the item (may be a narrative description, a HCPCS code, HCPCS code narrative, or brand name/model number)
• For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
• For supplies - In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately)
• Quantity to be dispensed, if applicable
• Treating Practitioner Name or NPI
• Treating practitioner's signature

Testing Requirements

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. These are outlined in the LCD:

• Basic requirements have been met (patient has diabetes as indicated in their medical record and you have ordered a blood glucose monitor and/or related testing supplies); and,
• Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described above; and,
• 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. The medical record should contain clinical rationale for excess testing as well as any changes to the diabetic treatment plan.

Continuous Glucose Monitors (CGMs)

Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met:

1. The beneficiary has diabetes mellitus; and
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and,
4. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and,
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.

For coverage and limitations of these supplies review Local Coverage Determination (LCD) L33822 and Policy Article A52464 and A55426.