Diabetic Services and Supplies

Policy ID: E-15-046

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: December 08, 2024

Revision Effective Date: March 03, 2025

Last Reviewed: January 14, 2025

Applies To: Commercial and Medicaid Expansion

Description

Diabetes outpatient self-management and training service is a program which educates individuals in self-monitoring of blood glucose, diet, exercise, and insulin management.

Orthotics protect, restore and/or improve the function of moveable parts of the body with orthopedic appliances or apparatus. Orthotic appliances or apparatus support, align, prevent and/or correct deformities.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Diabetic Equipment and Supplies

The following diabetic equipment and supplies designed for individual use are eligible for coverage when prescribed by a physician:

Insulin; or
Injection aids; or
Injection aids, including insulin; or
Syringes and needles; or
Insulin infusion related supplies; or
Pharmacological agents for controlling blood sugar; or
Blood glucose monitors; or
Monitor supplies; or
Skin prep supplies; or
Supplies.

Diabetic equipment and supplies are covered when the glucose monitor is covered.

Procedure Codes

A4206

A4207

A4208

A4209

A4210

A4211

A4213

A4215

A4224

A4225

A4230

A4231

A4232

A4233

A4234

A4235

A4236

A4244

A4245

A4246

A4247

A4248

A4250

A4252

A4253

A4255

A4256

A4257

A4258

A4259

A4271

A4369

A4371

A4405

A4406

A4456

A5120

A9275

E0607

E0620

E1399

E2100

E2101

E2104

J1610

J1815

J1817

S5000

S5001

S5550

S5551

S5552

S5553

S5560

S5561

S5565

S5566

S5570

S5571

S8490

Quantity Level Limits (QLL) for test strips, lancets, lens shield cartridge

The quantity of test strips, lancets and replacement lens shield cartridges that are covered depends on the medical needs of the diabetic individual according to the following guidelines:

Pediatric

Less than or equal to 12 years old and under:

Test strips*- 300 per one (1) month and 900 every 90 days; and
Lancets**- 300 per one (1) month and 900 every 90 days; or
Lens shield cartridge- one (1) every one (1) month.

Adolescent/Adult

Greater than or equal to 13 years old:

Test strips*- 204 up to 34 days and 612 every 35-90 days; and
Lancets**- 204 up to 34 days and 612 every 35-90 days; or
Lens shield cartridge- one (1) every one (1) month.

When ALL of the following criteria are met:

The equipment and supplies are prescribed by a physician; and
The glucose monitor is covered; and
The supplier of the test strips and lancets or lens shield cartridge maintains in its records the order from the treating physician; and
The individual has nearly exhausted the supply of test strips and lancets or useful life of one lens shield cartridge previously dispensed.

*Glucose test strips - one (1) unit of service = one (1) box (50-51 strips).

**Lancets- one (1) unit of service = one (1) box (100 lancets).

Testing supplies are considered not medically necessary if all of the above criteria are not met.

All Diabetic Individuals

Spring powered device- one (1) every six (6) months.

More than one (1) spring powered device is considered not medically necessary.

Procedure Codes

A4253

A4257

A4258

A4259

QLLs Exceeded for test strips, lancets, lens shield cartridge

Policy Application

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

QLLs that exceed the allowed amount of strips, lancet, and lens shield cartridges are covered when ALL of the following are met.

The equipment and supplies are prescribed by a physician; and
The glucose monitor is covered; and
The supplier of the test strips and lancets, or lens shield cartridge maintains in its records the order from the treating physician; and
The individual has nearly exhausted the supply of test strips and lancets, or useful life of one (1) lens shield cartridge previously dispensed; and
The treating physician has ordered a frequency of testing that exceeds the frequency guidelines in this policy and has documented in the individual's medical record the specific reason for the additional materials for that particular individual; and
The treating physician has seen the individual and has evaluated their diabetes control within six (6) months prior to ordering quantities of strips and lancets, or lens shield cartridges that exceed the frequency guidelines in this policy; and
If refills of quantities of supplies that exceed the frequency guidelines in this policy 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 individual is actually testing or a copy of the individual's log) or in the supplier's records (e.g., a copy of the individual's log) that the individual is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the individual is regularly using quantities of supplies that exceed the frequency guidelines in this policy, new documentation must be present at least every six (6) months.

QLLs of test strips, lancets, or lens shield cartridges are considered not medically necessary if they exceed the frequency guidelines in this policy and the above criteria are not met.

Procedure Codes

A4253

A4257

A4259

I-Port Injection Port (Patton Medical Devices)

Policy Application

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

I-Port Injection Port (Patton Medical Devices) is considered experimental/investigational and, therefore, non-covered. There is a lack of scientific-based evidence of long-term studies demonstrating the safety and efficacy of this device.

Procedure Code

E1399

Policy Application

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Diabetes Outpatient Self-Management and Training Service may be considered medically necessary for the diabetic individual in ANY of the following circumstances:

Initial diagnosis of diabetes; or
Significant change in the individual's symptoms or condition ; such as fluctuation in blood glucose values, risk for hypoglycemic events; or
Uncontrolled diabetes despite optimization of medical therapy; or
The introduction of new medication or new therapeutic process in the treatment/management of the individual's symptoms/condition.

All other circumstances are considered not medically necessary.

Procedure Codes

G0108

G0109

S9140

S9141

S9145

S9455

S9460

98960

98961

98962

Orthotics

Policy Application

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Diabetic shoes and the Lang Medical Shoe foot pressure off-loading/supportive devices inserts and/or modifications to those shoes are eligible when BOTH of the following criteria are met:

The individual has diabetes mellitus; and
The individual has one (1) or more of the following conditions:
- Previous amputation of the other foot or part of either foot; or
- History of previous foot ulceration of either foot; or
- History of pre-ulcerative calluses of either foot; or
- Peripheral neuropathy with evidence of callus formation of either foot; or
- Foot deformity of either foot; or
- Poor circulation in either foot.

All other indications are considered not medically necessary.

Procedure Codes

A5500

A5501

A5503

A5504

A5505

A5506

A5507

A5510

A5512

A5513

A5514

A9283

L2999

QLLs for diabetic shoes and inserts

Policy Application

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Individuals meeting the above orthotic coverage is limited to ONE (1) of the following within one (1) calendar year:

One (1) pair of custom-molded shoes and two (2) pairs of inserts; or
One (1) pair of depth shoes and three (3) pairs of inserts (not including the non-customized removable inserts provided with such shoes).

Note: A modification of a custom-molded or depth shoe will be covered as a substitute for an insert.

Diabetic shoes and custom inserts will be denied as not medically necessary if the above criteria are not met.

Procedure Codes

A5500

A5501

A5503

A5504

A5505

A5506

A5507

A5510

A5512

A5513

A5514

A9283

E1399

L2999

Deluxe Shoe Feature

Policy Application

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

is non-covered because it does not contribute to the therapeutic function of the shoe. Features may include but are not limited to style, color or type of leather.

Procedure Code

A5508

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes : A4224, A4225, A4230, A4231, and A4232.

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3521

E08.3522

E08.3523

E08.3529

E08.3531

E08.3532

E08.3533

E08.3539

E08.3541

E08.3542

E08.3543

E08.3549

E08.3551

E08.3552

E08.3553

E08.3559

E08.3591

E08.3592

E08.3593

E08.3599

E08.36

E08.37X1

E08.37X2

E08.37X3

E08.37X9

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E08.65

E08.69

E08.8

E08.9

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3521

E09.3522

E09.3523

E09.3529

E09.3531

E09.3532

E09.3533

E09.3539

E09.3541

E09.3542

E09.3543

E09.3549

E09.3551

E09.3552

E09.3553

E09.3559

E09.3591

E09.3592

E09.3593

E09.3599

E09.36

E09.37X1

E09.37X2

E09.37X3

E09.37X9

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E09.65

E09.69

E09.8

E09.9

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3539

E10.3541

E10.3542

E10.3543

E10.3549

E10.3551

E10.3552

E10.3553

E10.3559

E10.3591

E10.3592

E10.3593

E10.3599

E10.36

E10.37X1

E10.37X2

E10.37X3

E10.37X9

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.10

E11.11

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3521

E11.3522

E11.3523

E11.3529

E11.3531

E11.3532

E11.3533

E11.3539

E11.3541

E11.3542

E11.3543

E11.3549

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.37X9

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3521

E13.3522

E13.3523

E13.3529

E13.3531

E13.3532

E13.3533

E13.3539

E13.3541

E13.3542

E13.3543

E13.3549

E13.3551

E13.3552

E13.3553

E13.3559

E13.3591

E13.3592

E13.3593

E13.3599

E13.36

E13.37X1

E13.37X2

E13.37X3

E13.37X9

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

E13.65

E13.69

E13.8

E13.9

E15

E16.0

E16.3

E16.8

E16.9

E89.1

O24.011

O24.012

O24.013

O24.019

O24.02

O24.03

O24.111

O24.112

O24.113

O24.119

O24.12

O24.13

O24.311

O24.312

O24.313

O24.319

O24.32

O24.33

O24.410

O24.414

O24.415

O24.419

O24.420

O24.424

O24.425

O24.429

O24.430

O24.434

O24.435

O24.439

O24.811

O24.812

O24.813

O24.819

O24.82

O24.83

O24.911

O24.912

O24.913

O24.919

O24.92

O24.93

O99.810

O99.814

O99.815

P70.2

Z79.4

Covered Diagnosis codes for Procedure Codes: A4226, A4271,E2104, G0564, and G0565

(Short and Long Term Interstitial)

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3291

E10.3292

E10.3293

E10.3311

E10.3312

E10.3313

E10.3391

E10.3392

E10.3393

E10.3411

E10.3412

E10.3413

E10.3491

E10.3492

E10.3493

E10.3511

E10.3512

E10.3513

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3541

E10.3542

E10.3543

E10.3551

E10.3552

E10.3553

E10.3591

E10.3592

E10.3593

E10.36

E10.37X1

E10.37X2

E10.37X3

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.10

E11.11

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3291

E11.3292

E11.3293

E11.3311

E11.3312

E11.3313

E11.3391

E11.3392

E11.3393

E11.3411

E11.3412

E11.3413

E11.3491

E11.3492

E11.3493

E11.3511

E11.3512

E11.3513

E11.3521

E11.3522

E11.3523

E11.3531

E11.3532

E11.3533

E11.3541

E11.3542

E11.3543

E11.3551

E11.3552

E11.3553

E11.3591

E11.3592

E11.3593

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

O24.011

O24.012

O24.013

O24.019

O24.02

O24.03

O24.111

O24.112

O24.113

O24.119

O24.12

O24.13

O24.414

O24.419

O24.424

O24.429

O24.434

O24.439

Z79.4

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019 New policy

Internal Medical Policy Committee 4-16-2020

Removed procedure code A9274 from policy as this is part of the Portable External Infusion Pump policy

Internal Medical Policy Committee 7-22-2020 Revision

Added Additional criteria to the Diabetes Outpatient Self-Management and Training Service section, and
Removed procedure codes A4222, E0784, E0787, K0552, K0601, K0602, K0603, K0604 and K0605 as these codes are part of the Portable External Infusion Pump policy, and
Updated diagnosis codes

Internal Medical Policy Committee 7-22-2021 Annual Review-no change in criteria

Internal Medical Policy Committee 7-21-2022 Annual Review-no change in criteria

Internal Medical Policy Committee 11-29-2022 Policy Reviewed.

Internal Medical Policy Committee 11-15-2023 Annual Review-no change in criteria

Internal Medical Policy Committee 3-19-2024 Coding update

Effective April 01, 2024

Added new procedure codes A4271 and E2104

Effective May 06, 2024

Added procedure codes E2100; and
Added diagnosis codes E13.36; E15; E16.0; E16.3; E16.8; E16.9; E89.1; O24.415; O24.425; & O24.435.

Internal Medical Policy Committee 7-16-2024 Coding update - Effective September 02, 2024

Removed procedure codes A4226; A4238; A4239; A9276; A9277; A9278; E2102; E2103; 0446T; 0447T; 0448T; 95249; 95250 and 95251 (these codes are found in policy I-9001).

Internal Medical Policy Committee 1-14-2025 Annual review- no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-15-045

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: July 12, 2024

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Archived Date: March 02, 2025

Applies To: Commercial and Medicaid Expansion

Description

Diabetes outpatient self-management and training service is a program which educates individuals in self-monitoring of blood glucose, diet, exercise, and insulin management.

Policy Application

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Diabetic Equipment and Supplies

The following diabetic equipment and supplies designed for individual use are eligible for coverage when prescribed by a physician:

Insulin; or
Injection aids; or
Injection aids, including insulin; or
Syringes and needles; or
Insulin infusion related supplies; or
Pharmacological agents for controlling blood sugar; or
Blood glucose monitors; or
Monitor supplies; or
Skin prep supplies; or
Supplies.

Diabetic equipment and supplies are covered when the glucose monitor is covered.

Procedure Codes

A4206

A4207

A4208

A4209

A4210

A4211

A4213

A4215

A4224

A4225

A4230

A4231

A4232

A4233

A4234

A4235

A4236

A4244

A4245

A4246

A4247

A4248

A4250

A4252

A4253

A4255

A4256

A4257

A4258

A4259

A4271

A4369

A4371

A4405

A4406

A4456

A5120

A9275

E0607

E0620

E1399

E2100

E2101

E2104

J1610

J1815

J1817

S5000

S5001

S5550

S5551

S5552

S5553

S5560

S5561

S5565

S5566

S5570

S5571

S8490

Quantity Level Limits (QLL) for test strips, lancets, lens shield cartridge

The quantity of test strips, lancets and replacement lens shield cartridges that are covered depends on the medical needs of the diabetic individual according to the following guidelines:

Pediatric

Less than or equal to 12 years old and under:

Test strips*- 300 per one (1) month and 900 every 90 days; and
Lancets**- 300 per one (1) month and 900 every 90 days; or
Lens shield cartridge- one (1) every one (1) month.

Adolescent/Adult

Greater than or equal to 13 years old:

Test strips*- 204 up to 34 days and 612 every 35-90 days; and
Lancets**- 204 up to 34 days and 612 every 35-90 days; or
Lens shield cartridge- one (1) every one (1) month.

When ALL of the following criteria are met:

The equipment and supplies are prescribed by a physician; and
The glucose monitor is covered; and
The supplier of the test strips and lancets or lens shield cartridge maintains in its records the order from the treating physician; and
The individual has nearly exhausted the supply of test strips and lancets or useful life of one lens shield cartridge previously dispensed.

*Glucose test strips - one (1) unit of service = one (1) box (50-51 strips).

**Lancets- one (1) unit of service = one (1) box (100 lancets).

Testing supplies are considered not medically necessary if all of the above criteria are not met.

All Diabetic Individuals

Spring powered device- one (1) every six (6) months.

More than one (1) spring powered device is considered not medically necessary.

Procedure Codes

A4253

A4257

A4258

A4259

QLLs Exceeded for test strips, lancets, lens shield cartridge

QLLs that exceed the allowed amount of strips, lancet, and lens shield cartridges are covered when ALL of the following are met.

The equipment and supplies are prescribed by a physician; and
The glucose monitor is covered; and
The supplier of the test strips and lancets, or lens shield cartridge maintains in its records the order from the treating physician; and
The individual has nearly exhausted the supply of test strips and lancets, or useful life of one (1) lens shield cartridge previously dispensed; and
The treating physician has ordered a frequency of testing that exceeds the frequency guidelines in this policy and has documented in the individual's medical record the specific reason for the additional materials for that particular individual; and
The treating physician has seen the individual and has evaluated their diabetes control within six (6) months prior to ordering quantities of strips and lancets, or lens shield cartridges that exceed the frequency guidelines in this policy; and
If refills of quantities of supplies that exceed the frequency guidelines in this policy 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 individual is actually testing or a copy of the individual's log) or in the supplier's records (e.g., a copy of the individual's log) that the individual is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the individual is regularly using quantities of supplies that exceed the frequency guidelines in this policy, new documentation must be present at least every six (6) months.

QLLs of test strips, lancets, or lens shield cartridges are considered not medically necessary if they exceed the frequency guidelines in this policy and the above criteria are not met.

Procedure Codes

A4253

A4257

A4259

I-Port Injection Port (Patton Medical Devices)

Procedure Code

E1399

Diabetes Outpatient Self-Management and Training Service may be considered medically necessary for the diabetic individual in ANY of the following circumstances:

Initial diagnosis of diabetes; or
Significant change in the individual's symptoms or condition ; such as fluctuation in blood glucose values, risk for hypoglycemic events; or
Uncontrolled diabetes despite optimization of medical therapy; or
The introduction of new medication or new therapeutic process in the treatment/management of the individual's symptoms/condition.

All other circumstances are considered not medically necessary.

Procedure Codes

G0108

G0109

S9140

S9141

S9145

S9455

S9460

98960

98961

98962

Orthotics

Diabetic shoes and the Lang Medical Shoe foot pressure off-loading/supportive devices inserts and/or modifications to those shoes are eligible when BOTH of the following criteria are met:

The individual has diabetes mellitus; and
The individual has one (1) or more of the following conditions:
- Previous amputation of the other foot or part of either foot; or
- History of previous foot ulceration of either foot; or
- History of pre-ulcerative calluses of either foot; or
- Peripheral neuropathy with evidence of callus formation of either foot; or
- Foot deformity of either foot; or
- Poor circulation in either foot.

All other indications are considered not medically necessary.

Procedure Codes

A5500

A5501

A5503

A5504

A5505

A5506

A5507

A5510

A5512

A5513

A5514

A9283

L2999

QLLs for diabetic shoes and inserts

Individuals meeting the above orthotic coverage is limited to ONE (1) of the following within one (1) calendar year:

One (1) pair of custom-molded shoes and two (2) pairs of inserts; or
One (1) pair of depth shoes and three (3) pairs of inserts (not including the non-customized removable inserts provided with such shoes).

Note: A modification of a custom-molded or depth shoe will be covered as a substitute for an insert.

Diabetic shoes and custom inserts will be denied as not medically necessary if the above criteria are not met.

Procedure Codes

A5500

A5501

A5503

A5504

A5505

A5506

A5507

A5510

A5512

A5513

A5514

A9283

L2999

Deluxe Shoe Feature is non-covered because it does not contribute to the therapeutic function of the shoe. Features may include but are not limited to style, color or type of leather.

Procedure Code

A5508

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes : A4224, A4225, A4230, A4231, and A4232.

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3521

E08.3522

E08.3523

E08.3529

E08.3531

E08.3532

E08.3533

E08.3539

E08.3541

E08.3542

E08.3543

E08.3549

E08.3551

E08.3552

E08.3553

E08.3559

E08.3591

E08.3592

E08.3593

E08.3599

E08.36

E08.37X1

E08.37X2

E08.37X3

E08.37X9

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E08.65

E08.69

E08.8

E08.9

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3521

E09.3522

E09.3523

E09.3529

E09.3531

E09.3532

E09.3533

E09.3539

E09.3541

E09.3542

E09.3543

E09.3549

E09.3551

E09.3552

E09.3553

E09.3559

E09.3591

E09.3592

E09.3593

E09.3599

E09.36

E09.37X1

E09.37X2

E09.37X3

E09.37X9

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E09.65

E09.69

E09.8

E09.9

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3539

E10.3541

E10.3542

E10.3543

E10.3549

E10.3551

E10.3552

E10.3553

E10.3559

E10.3591

E10.3592

E10.3593

E10.3599

E10.36

E10.37X1

E10.37X2

E10.37X3

E10.37X9

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.10

E11.11

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3521

E11.3522

E11.3523

E11.3529

E11.3531

E11.3532

E11.3533

E11.3539

E11.3541

E11.3542

E11.3543

E11.3549

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.37X9

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3521

E13.3522

E13.3523

E13.3529

E13.3531

E13.3532

E13.3533

E13.3539

E13.3541

E13.3542

E13.3543

E13.3549

E13.3551

E13.3552

E13.3553

E13.3559

E13.3591

E13.3592

E13.3593

E13.3599

E13.36

E13.37X1

E13.37X2

E13.37X3

E13.37X9

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

E13.65

E13.69

E13.8

E13.9

E15

E16.0

E16.3

E16.8

E16.9

E89.1

O24.011

O24.012

O24.013

O24.019

O24.02

O24.03

O24.111

O24.112

O24.113

O24.119

O24.12

O24.13

O24.311

O24.312

O24.313

O24.319

O24.32

O24.33

O24.410

O24.414

O24.415

O24.419

O24.420

O24.424

O24.425

O24.429

O24.430

O24.434

O24.435

O24.439

O24.811

O24.812

O24.813

O24.819

O24.82

O24.83

O24.911

O24.912

O24.913

O24.919

O24.92

O24.93

O99.810

O99.814

O99.815

P70.2

Z79.4

Covered Diagnosis codes for Procedure Codes: A4271, and E2104 (Short and Long Term Interstitial)

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3291

E10.3292

E10.3293

E10.3311

E10.3312

E10.3313

E10.3391

E10.3392

E10.3393

E10.3411

E10.3412

E10.3413

E10.3491

E10.3492

E10.3493

E10.3511

E10.3512

E10.3513

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3541

E10.3542

E10.3543

E10.3551

E10.3552

E10.3553

E10.3591

E10.3592

E10.3593

E10.36

E10.37X1

E10.37X2

E10.37X3

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.10

E11.11

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3291

E11.3292

E11.3293

E11.3311

E11.3312

E11.3313

E11.3391

E11.3392

E11.3393

E11.3411

E11.3412

E11.3413

E11.3491

E11.3492

E11.3493

E11.3511

E11.3512

E11.3513

E11.3521

E11.3522

E11.3523

E11.3531

E11.3532

E11.3533

E11.3541

E11.3542

E11.3543

E11.3551

E11.3552

E11.3553

E11.3591

E11.3592

E11.3593

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

O24.011

O24.012

O24.013

O24.019

O24.02

O24.03

O24.111

O24.112

O24.113

O24.119

O24.12

O24.13

O24.414

O24.419

O24.424

O24.429

O24.434

O24.439

Z79.4

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019 New policy

Internal Medical Policy Committee 4-16-2020

Removed procedure code A9274 from policy as this is part of the Portable External Infusion Pump policy

Internal Medical Policy Committee 7-22-2020 Revision

Added Additional criteria to the Diabetes Outpatient Self-Management and Training Service section, and
Removed procedure codes A4222, E0784, E0787, K0552, K0601, K0602, K0603, K0604 and K0605 as these codes are part of the Portable External Infusion Pump policy, and
Updated diagnosis codes

Internal Medical Policy Committee 7-22-2021 Annual Review-no change in criteria

Internal Medical Policy Committee 7-21-2022 Annual Review-no change in criteria

Internal Medical Policy Committee 11-29-2022 Policy Reviewed.

Internal Medical Policy Committee 11-15-2023 Annual Review-no change in criteria

Internal Medical Policy Committee 3-19-2024 Coding update

Effective April 01, 2024

Added new procedure codes A4271 and E2104

Effective May 06, 2024

Added procedure codes E2100; and
Added diagnosis codes E13.36; E15; E16.0; E16.3; E16.8; E16.9; E89.1; O24.415; O24.425; & O24.435.

Internal Medical Policy Committee 7-16-2024 Coding update - Effective September 02, 2024

Removed procedure codes A4226; A4238; A4239; A9276; A9277; A9278; E2102; E2103; 0446T; 0447T; 0448T; 95249; 95250 and 95251 (these codes are found in policy I-9001).

Medical Policies Quick Search

Diabetic Services and Supplies

Description

Policy Application

Criteria

Diabetic Equipment and Supplies

Procedure Codes

Quantity Level Limits (QLL) for test strips, lancets, lens shield cartridge

Pediatric

Adolescent/Adult

All Diabetic Individuals

Procedure Codes

QLLs Exceeded for test strips, lancets, lens shield cartridge

Policy Application

Procedure Codes

I-Port Injection Port (Patton Medical Devices)

Policy Application

Procedure Code

Policy Application

Procedure Codes

Orthotics

Policy Application

Procedure Codes

QLLs for diabetic shoes and inserts

Policy Application

Procedure Codes

Policy Application

Procedure Code

Diagnosis Codes

Covered Diagnosis codes for Procedure Codes: A4226, A4271,E2104, G0564, and G0565

(Short and Long Term Interstitial)

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Diabetic Equipment and Supplies

Procedure Codes

Quantity Level Limits (QLL) for test strips, lancets, lens shield cartridge

Pediatric

Adolescent/Adult

All Diabetic Individuals

Procedure Codes

QLLs Exceeded for test strips, lancets, lens shield cartridge

Procedure Codes

I-Port Injection Port (Patton Medical Devices)

Procedure Code

Procedure Codes

Orthotics

Procedure Codes

QLLs for diabetic shoes and inserts

Procedure Codes

Procedure Code

Diagnosis Codes

Covered Diagnosis codes for Procedure Codes: A4271, and E2104 (Short and Long Term Interstitial)

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer