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Diabetic Services and Supplies

Section: Durable Medical Equipment
Effective Date: July 01, 2018
Revised Date: August 13, 2019
Last Reviewed: July 16, 2019

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 (orthopedic apparatus and appliances) are used to prevent injury by protecting and supporting a weak or deformed body member to improve function, or restricting or eliminating motion in a diseased or injured part of the body.

Criteria

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 devices and 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 A4222 A4224 A4225 A4230 A4231 A4232
A4233 A4234 A4235 A4236 A4244 A4245 A4246
A4247 A4248 A4250 A4252 A4253 A4255 A4256
A4257 A4258 A4259 A4369 A4371 A4405 A4406
A4456 A5120 A9274 A9275 E0607 E0620 E0784
E1399 E2100 E2101 J1610 J1815 J1817 K0552
K0601 K0602 K0603 K0604 K0605 S5000 S5001
S5550 S5551 S5552 S5553 S5556 S5560 S5561
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 member 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 Patients

  • 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 member’s log) or in the supplier’s records (e.g., a copy of the member’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)

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 Codes

E1399

Diabetes Outpatient Self-Management and Training Service may be considered medically necessary for the diabetic individual when prescribed by a licensed physician in ANY of the following circumstances:

  • Initial diagnosis of diabetes; or
  • Significant change in the individual's symptoms or condition; 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 insert (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 Codes

A5508

Diagnosis Codes

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 E11.21
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 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 O24.419 O24.420
O24.424 O24.429 O24.430 O24.434 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

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