Diabetic Supplies

Policy No: 128

Date of Origin: 09/01/2018
Section: Administrative
Last Reviewed: 08/01/2019
Last Revised: 08/01/2019
Approved: 08/15/2019
Effective: 09/01/2019

This policy does not apply to facilities (hospitals, surgery centers, kidney centers, etc....)


Glucose Monitor
A medical device for determining the approximate concentration of glucose in the blood.

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 is 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 has 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: Two (2) units of HCPCS A4250 are purchased on 9/1/2018. The member may receive up to four (4) additional units of HCPCS A4250 prior to 12/31/2018, for a total of six (6) units of HCPCS A4250 purchased within a 3 month/90 day period.

Diabetic supplies
HCPCS CodeCode DescriptionMaximum UnitsFrequency
A4210Needle-free injection device, each21 year/365 days
A4230Infusion set for external insulin pump, non-needle cannula type903 months/90 days
A4231Infusion set for external insulin pump, needle type903 months/90 days
A4253Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips183 months/90 days
A4257Replacement lens shield cartridge for use with laser skin piercing device, each33 months/90 days
A4258Spring-powered device for lancet, each21 year/365 days
A9275Home glucose disposable monitor, includes test strips123 months/90 days
A9276Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply903 months/90 days
A9277Transmitter; external, for use with interstitial continuous glucose monitoring system41 year/365 days
A9278Receiver (monitor); external, for use with interstitial continuous glucose monitoring system22 years/730 days
K0553Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service33 months/90 days
K0554Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system22 years/730 days

The maximum units for A9276 and K0553 are based on the code definitions and are included in the table for clarity.


Center for Medicare & Medicaid Services (CMS) Local Coverage Determination (LCD), L33822


Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.