Policy No: 128
Date of Origin: 09/01/2018
Last Reviewed: 08/01/2019
Last Revised: 08/01/2019
This policy does not apply to facilities (hospitals, surgery centers, kidney centers, etc....)
A medical device for determining the approximate concentration of glucose in the blood.
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.
Center for Medicare & Medicaid Services (CMS) Local Coverage Determination (LCD), L33822
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