Diabetic Supplies

Policy No: 128
Date of Origin: 09/01/2018
Section: Administrative
Last Reviewed: 12/01/2023
Last Revised: 01/01/2023
Approved: 12/14/2023
Effective: 01/01/2024
Policy Applies To: Group & Individual

This policy applies only to physicians and other qualified health care professionals, including Durable Medical Equipment (DME) providers.

Definitions

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 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 9/1/2023. The member may receive up to thirty (30) additional units of HCPCS A9276 prior to 12/31/2023, for a total of ninty (90) units of HCPCS A9276 purchased within a 3 month/90-day period.

Diabetic supplies

HCPCS Code

Code Description

Maximum Units

Frequency

A4238

Supply allowance for adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service

3

3 months/90 days

A4239

Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service

3

3 months/90 days

A4253

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

18

3 months/90 days

A4257

Replacement lens shield cartridge for use with laser skin piercing device, each

3

3 months/90 days

A4258

Spring-powered device for lancet, each

2

1 year/365 days

A9276

Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply

90

3 months/90 days

A9277

Transmitter; external, for use with interstitial continuous glucose monitoring system

5

1 year/365 days

A9278

Receiver (monitor); external, for use with interstitial continuous glucose monitoring system

1

5 years/1825 days

E2102

Adjunctive continuous glucose monitor or receiver

1

5 years/1825 days

E2103

Non-adjunctive, non-implanted continuous glucose monitor or receiver

1

5 years/1825 days

The maximum units for A9276, A4238 and A4239 are based on the code definitions and are included in the table for clarity.

We recognize that previously listed codes A4210, A4230 and A4231 are active HCPCS Codes, however they are non-reimbursable.

References

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

Noridian Healthcare Solutions, Reasonable Useful Lifetime- Clarification. Reasonable Useful Lifetime

Disclaimer

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.