Physicians Are You Ordering Glucose Monitors and Supplies for Your Patients?

The Comprehensive Error Rate Testing (CERT) program has noted a high error rate for glucose monitor claims. 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 that your patient or a caregiver is sufficiently trained to use the prescribed device appropriately. (Reference: CMS publication 100-3.)

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’s name or NPI
  • Treating practitioner's signature

Testing Requirements

Medicare will provide coverage for the diabetic testing regimen as outlined in the Glucose Monitors Local Coverage Determination (LCD) (L33822):

Treatment Regimen Basic Coverage for Test Strips and Lancets Prescribed Testing Frequency
Insulin treated Up to 300 per 3 months Up to 3 times a day
Non-insulin treated Up to 100 per 3 months Once a day

 

For your patients who require additional testing per day, or the quantities of supplies ordered exceeds Medicare's standard utilization parameters, there are some additional documentation requirements that must be met. These are outlined in the Glucose Monitors LCD (L33822):

  • Basic requirements outlined above have been met; and,
  • Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, you have had an in-person visit* with your patient 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, you 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)

A therapeutic or non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone blood glucose monitor (BGM) to confirm testing results. A non-therapeutic or adjunctive CGM requires the user verify their glucose levels or trends displayed on a CGM with a BGM prior to making treatment decisions. On February 28, 2022, CMS determined that both therapeutic/non-adjunctive and non-therapeutic/adjunctive CGMs may be classified as DME.

CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-5) are met**:

  1. Your patient has diabetes mellitus; and
  2. Your patient is insulin-treated with multiple (three or more) daily administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; [For coverage and limitations relevant to insulin treatment via a continuous subcutaneous insulin infusion pump, review  the External Infusion Pumps LCD (L33794) and LCD-related Policy Article (A52507)]; and,
  3. Your patient’s insulin treatment regimen requires frequent adjustment by the patient or caregiver on the basis of BGM or CGM testing results; and,
  4. Within six (6) months prior to ordering the CGM, you have an in-person visit* with your patient to evaluate their diabetes control and determined that criteria (1-3) above are met; and,
  5. Every six (6) months following the initial prescription of the CGM, you have an in-person visit* with your patient to assess adherence to their CGM regimen and diabetes treatment plan.

For coverage and limitations of these supplies review the Glucose Monitors LCD (L33822) and LCD-related Policy Articles A52464 and A55426
*Note that during the Public Health Emergency, CMS has waived the in-person visit requirement. This may be accomplished by Medicare-approved methods of telehealth.

**Note that during the Public Health Emergency, CMS has instructed the A/B/DME MACs to not enforce the clinical indications of coverage for CGMs. Additional details at CMS Issues Interim Final Rules with Comment (CMS-1744-IFC & CMS-5531-IFC) - COVID-19 Public Health Emergency - Revised

Publication History

Date of Change Description
July 18, 2022 Added references to Glucose Monitors LCD (L33822), External Infusion Pumps LCD (L33794), and LCD-related Policy Article (A52507); revised the diabetic testing regimen language; added information in regard to treatment with a therapeutic/non-adjunctive CGM and non-therapeutic/adjunctive CGM; changed insulin injections to insulin administrations; removed the four or more times a day testing requirement; added information in regard to non-enforcement directives and waivers associated with the COVID-19 PHE
July 2020 Revised
November 9, 2018 Originally Published

 

            Last Updated Thu, 21 Jul 2022 13:09:05 +0000