Policy Statement
This policy applies only to the supplies/accessories used with glucose monitors.
Supplies/accessories used with a glucose monitor may be covered when criteria for the monitor are met. Our health plan utilizes Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCD) to determine the reasonable and necessary maximum quantities and frequencies for diabetic supply purchases. Our health plan reserves the right to assign a maximum limit to codes not included in CMS guidelines.
When the total units of service for a Healthcare Common Procedure Coding System (HCPCS) code have exceeded the maximum allowed within the specified time frame, our health plan will allow up to that limit and deny the remaining units. Our health plan will allow up to a 10-day grace period.
Example: Sixty (60) units of HCPCS A9276 are purchased on 9/1/2025. The member may receive up to thirty (30) additional units of HCPCS A9276 prior to 12/31/2025, for a total of ninety (90) units of HCPCS A9276 purchased within a 3 month/90-day period.
