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 diabeticindividual according to the following guidelines:
Pediatric
Less than or equal to12 years old and under:
- Test strips*- 300 perone (1) month and 900 every 90 days; and
- Lancets**- 300 perone (1) month and 900 every 90 days; or
- Lens shield cartridge- one (1) everyone (1) month.
Adolescent/Adult
Greater than or equal to13 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) everyone (1) month.
WhenALLof 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) everysix (6) months.
More than one (1) spring powered deviceis considerednot medically necessary.
Procedure Codes
