Audience
Zip code - drawer
County - drawer

Sign in

Sign in

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....)

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 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.

HCPCS Code Code Description Maximum Units Frequency
A4210 Needle-free injection device, each 2 1 year/365 days
A4230 Infusion set for external insulin pump, non-needle cannula type 90 3 months/90 days
A4231 Infusion set for external insulin pump, needle type 90 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
A9275 Home glucose disposable monitor, includes test strips 12 3 months/90 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 4 1 year/365 days
A9278 Receiver (monitor); external, for use with interstitial continuous glucose monitoring system 2 2 years/730 days
K0553 Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service 3 3 months/90 days
K0554 Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system 2 2 years/730 days

 

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

References

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

Cross References

Correct Coding Guidelines

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.