Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Home Blood Glucose Monitors and Supplies
Policy #:MA05.015c

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

HOME BLOOD GLUCOSE MONITORS
Home blood glucose monitors when prescribed by a professional provider, are considered medically necessary and, therefore, covered, when ALL of the following coverage criteria are met:
  • The individual is diagnosed with diabetes by having one of the following:
    • A fasting blood glucose greater than or equal to 126 mg/dL on two different occasions;
    • A 2-hour post-glucose challenge greater than or equal to 200 mg/dL on two different occasions;
    • A random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes.
  • The individual is capable of being trained to use the glucose monitor prescribed in an appropriate manner or another responsible individual can be trained to use the equipment and monitor the individual that is being treated for diabetes.
  • The glucose monitor is designed for home, rather than clinical use.

HOME BLOOD GLUCOSE MONITORS WITH SPECIAL FEATURES
Home blood glucose monitors with special features, are considered medically necessary and, therefore, covered, when the coverage criteria above are met and the treating professional provider documents the following criteria:
  • A blood glucose monitor with integrated voice synthesizer (E2100) when used for individuals with a severe visual impairment (i.e., best corrected visual acuity of 20/200 or worse in at least one eye) who require use of this special monitoring system.
  • A blood glucose monitor with integrated lancing/blood sample ( E2101) when used for individuals with impairment of manual dexterity.

Reflectance colorimeter devices are used for measuring blood glucose levels in clinical settings. Some types of home blood glucose monitors that use the reflectance colorimeter technology in the monitors may be eligible for coverage.

SUPPLIES
Lancets (A4259), blood glucose test reagent strips (A4253), glucose control solutions (A4256), and spring-powered devices for lancets (A4258), are covered for individuals for whom the glucose monitor is covered. More than one spring-powered device (A4258) per 6 months is considered not medically necessary and, therefore, not covered.

The quantity of test strips (A4253) and lancets (A4259) that are covered depends on the usual medical needs of the diabetic individual and whether or not the individual is being treated with insulin, regardless of their diagnostic classification of Type 1 or Type 2 diabetes mellitus. Coverage of testing supplies is based on the following guidelines:

Usual Utilization
  • For an individual who is not currently being treated with insulin injections, up to 100 test strips and up to 100 lancets every 3 months are covered if the basic coverage criteria above are met.
  • For an individual who is currently being treated with insulin injections, up to 300 test strips and up to 300 lancets every 3 months are covered if basic criteria above are met.

High Utilization
  • For an individual who is not currently being treated with insulin injections, more than 100 test strips and more than 100 lancets every 3 months are covered if all of the following criteria are met:
    • The coverage criteria listed above for home glucose monitors and related accessories and supplies are met; and,
    • The treating professional provider has seen the individual and has evaluated their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines; and,
    • If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the professional provider's records (e.g., a specific narrative statement that adequately documents the frequency at which the individual is actually testing or a copy of the individual's log) that the individual is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the individual is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.
  • For an individual who is currently being treated with insulin injections, more than 300 test strips and more than 300 lancets every 3 months are covered if all of the following criteria are met:
    • The coverage criteria listed above for home glucose monitors and related accessories and supplies are met; and,
    • The treating professional provider has seen the individual and has evaluated their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines; and,
    • If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the professional provider's records (e.g., a specific narrative statement that adequately documents the frequency at which the individual is actually testing or a copy of the individual's log) that the individual is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the individual is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.

PREFERRED BRANDS

Blood glucose meters and test strips for Medicare Advantage members must be a preferred brand product for coverage, with no coinsurance, copayment, or deductible.

The Company preferred brands are:
  • Accu-Chek® products (Roche, Inc.)
  • One Touch® products (Life scan Inc)

Blood glucose meters and test strips other than Accu-Chek and One-Touch are not covered, with the following exceptions:
  • Coverage of meters and supplies with special features for the visually impaired
  • Coverage of meters and supplies that are used with an insulin pump

Please refer to the Evidence of Coverage for more information.

NOT MEDICALLY NECESSARY

All other uses for home glucose monitors and related accessories and supplies are considered not medically necessary and, therefore, not covered.

A laser skin piercing device (E0620) and related lens shield cartridge (A4257) are considered not medically necessary and, therefore, not covered because the medical necessity has not been established.

NOT COVERED

Home blood glucose disposable monitors are not covered by the Company because they are an item or service not covered by Medicare because these monitors do not meet the definition of durable medical equipment (DME). Therefore, they are not eligible for reimbursement consideration.

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • The treating professional provider must have an in-person examination with the individual within the six (6) months prior to the date of the written order prior to delivery.
  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified item is:

CodeNarrative
E0607 Home blood glucose monitor    

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

Documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.

COLUMN I/COLUMN II REIMBURSEMENT EDITS

The reimbursement for the item(s) represented by the code(s) in column II are included in the reimbursement for the item represented by the code in column I.

Column I
Column II
E0607 A4233, A4234, A4235, A4236
E2100 A4233, A4234, A4235, A4236
E2101 A4233, A4234, A4235, A4236

Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, home blood glucose monitors and supplies are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.

Certain drugs and supplies are available through either the member's medical benefit or pharmacy benefit, depending on how the item is prescribed, dispensed, or administered. This medical policy only addresses instances when blood glucose monitors and supplies are covered under a member's medical benefit. It does not address instances when supplies may be covered under a member’s pharmacy benefit.

Description

Home blood glucose monitors are devices that measure capillary whole blood for determination of blood glucose levels. Results are displayed on a screen and may be stored in memory on the device for download or viewing at a later time. The test strips may be separate items that are inserted into the monitor or self-contained in a cylinder or disk-type mechanism.

Blood glucose monitors with integrated voice synthesizers for visually impaired individuals are devices that measure capillary whole blood for determination of blood glucose levels. Results are displayed on a screen but are also digitized and converted to sound output. Test results may also be stored in memory on the device for download or viewing at a later time. The test strips may be separate items that are inserted into the monitor or self-contained in a cylinder or disk-type mechanism.

Blood glucose monitors with integrated lancing and/or blood sampling are devices that measure capillary whole blood for determination of blood glucose levels. The lancing device for obtaining the capillary blood sample is integrated into the glucose monitor rather than a separate accessory. Test results may also be stored in memory on the device for download or viewing at a later time. The test strips may be separate items that are inserted into the monitor or self-contained in a cylinder or disk-type mechanism.

Reflectance colorimeter devices are meter devices that read color changes produced on specially treated reagent strips by glucose concentrations in the individual's blood. The individual, using a disposable sterile lancet, draws a drop of blood, places it on a reagent strip and, following instructions which may vary with the device used, inserts it into the device to obtain a reading.
References

Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis (NCA) for Home Blood GLUCOSE MONITORs (CAG-00161N). 40.2. Effective date; 6/19/2006. Available at: https://www.cms.gov/medicare-coverage-database/details/nca-details.aspx?NCAId=35&NCDId=222&ncdver=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=Ed%7cKey%7cSAD%7cFAQ&PolicyType=Final&s=All&KeyWord=glucose+monitor&KeyWordLookUp=Title&KeyWordSearchType=And&kq=true&bc=IAAAABAAAAAAAA%3d%3d&. Accessed March 6, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) NCD 40.4 Insulin syringe. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=133&ncdver=1&DocID=40.4&kq=true&bc=gAAAAAgAAAAAAA%3D%3D& Accessed March 6, 2018.

Medlearn matters SE0738. An Overview of Medicare Covered Diabetes Supplies and Services. August 28, 2012. Available at:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0738.pdf. Accessed March 6, 2018.

Noridian Healthcare Solutions. Local Coverage Article Glucose Monitors. (A52464). Original effective date; 10/01/2015. Revised effective date; 01/12/2017. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Glucose+Monitors/b300483e-8205-47cf-9a04-36bad7ac2eea. Accessed March 6, 2018.

Noridian Healthcare Solutions. Local Coverage Determination (LCD) for Glucose Monitors (L33822). Original effective date; 10/01/2015. Revised effective date; 01/12/2017. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Glucose+Monitors/b300483e-8205-47cf-9a04-36bad7ac2eea. Accessed March 6, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A


HCPCS Level II Code Number(s)

MEDICALLY NECESSARY


SUPPLIES

A4233 Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each

A4234 Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each

A4235 Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each

A4236 Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each

A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

A4255 Platforms for home blood glucose monitor, 50 per box

A4256 Normal, low, and high calibrator solution/chips

A4258 Spring-powered device for lancet, each

A4259 Lancets, per box of 100


HOME BLOOD GLUCOSE MONITORS

E0607 Home blood glucose monitor


HOME BLOOD GLUCOSE MONITORS WITH SPECIAL FEATURES

E2100 Blood glucose monitor with integrated voice synthesizer

E2101 Blood glucose monitor with integrated lancing/blood sample


NOT MEDICALLY NECESSARY

A4257 Replacement lens shield cartridge for use with laser skin piercing device, each

E0620 Skin piercing device for collection of capillary blood, laser, each


NOT COVERED

A9275 Home glucose disposable monitor, includes test strips



Revenue Code Number(s)

N/A

Coding and Billing Requirements

For glucose test strips (A4253), 1 unit of service = 50 strips. For lancets (A4259), 1 unit of service = 100 lancets.

Cross References

Attachment A: Home Blood Glucose Monitors and Supplies
Description: ICD-10 diagnosis codes






Policy History

MA05.015c
04/25/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Home Blood Glucose Monitors and Supplies.
12/29/2017This version of the policy will become effective 12/29/2017.
  • Information on preferred brands of blood glucose meters and test strips for Medicare Advantage members was added to the policy.
  • Modified statement on visual acuity.
  • The following codes were added to Attachment A:
    E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, O24.32
  • The following codes were removed from Attachment A:
    O24.414, O24.415, O24.419, O24.420, O24.424, O24.425, O24.429, O24.430, O24.434, O24.435, O24.439, O99.810, O99.814, O99.815, P70.2
  • The following codes were removed from the policy:
    A4244 Alcohol or peroxide, per pint
    A4245 Alcohol wipes, per box
    A4246 Betadine or pHisoHex solution, per pint
    A4247 Betadine or iodine swabs/wipes, per box
    A4250 Urine test or reagent strips or tablets (100 tablets or strips)

MA05.015b
10.01/2017This policy has been identified for the ICD-10 CM code update, effective 10/01/2017.

The following ICD-10 CM codes have been added to this policy: In Attachments A

E11.10 Type 2 diabetes mellitus with ketoacidosis without coma
E11.11 Type 2 diabetes mellitus with ketoacidosis with coma

MA05.015a
02/15/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on home blood glucose monitors.
10/01/2016This policy has been identified for the ICD-10 CM code update, effective 10/01/2016.

The following ICD-10 CM codes have been revised in this policy:

FROM: O24.011 Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester
TO: O24.011 Pre-existing type 1 diabetes mellitus, in pregnancy, first trimester

FROM: O24.012 Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester
TO: O24.012 Pre-existing type 1 diabetes mellitus, in pregnancy, second trimester

FROM; 24.013 Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester
TO; O24.013 Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester

TO; O24.019 Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester
FROM; O24.019 Pre-existing type 1 diabetes mellitus, in pregnancy, unspecified trimester

FROM; 24.02 Pre-existing diabetes mellitus, type 1, in childbirth
TO; O24.02 Pre-existing type 1 diabetes mellitus, in childbirth

FROM; O24.03 Pre-existing diabetes mellitus, type 1, in the puerperium
TO; O24.03 Pre-existing type 1 diabetes mellitus, in the puerperium

FROM; O24.111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester
TO; O24.111 Pre-existing type 2 diabetes mellitus, in pregnancy, first trimester

FROM; O24.112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
TO; O24.112 Pre-existing type 2 diabetes mellitus, in pregnancy, second trimester

FROM; O24.113 Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester
TO; O24.113 Pre-existing type 2 diabetes mellitus, in pregnancy, third trimester

FROM; O24.119 Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester
TO; O24.119 Pre-existing type 2 diabetes mellitus, in pregnancy, unspecified trimester

FROM: O24.12 Pre-existing diabetes mellitus, type 2, in childbirth
TO: O24.12 Pre-existing type 2 diabetes mellitus, in childbirth

FROM: O24.13 Pre-existing diabetes mellitus, type 2, in the puerperium
TO: O24.13 Pre-existing type 2 diabetes mellitus, in the puerperium


The following ICD-10 CM codes have been deleted from this policy:

E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359,E09.321, E09.329, E09.331, E09.339 E09.341, E09.349, E09.351, E09.359, E10.321, E10.329, E10.331 E10.339, E10.341, E10.349 E10.351, E10.359, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359

The following ICD-10 CM codes have been added to this policy:

E08.3211, E08.3212, E08.3213, E08.3219, E08.3291, E08.3292, E08.3293, E08.3299, E08.3311, E08.3312, E08.3313, E08.3319, E08.3391, E08.3392, E08.3393, E08.3399, E08.3411, E08.3412, E08.3413, E08.3419, E08.3491, E08.3492, E08.3493, E08.3499, E08.3511, E08.3512, E08.3513 E08.3519, E08.3521, E08.3522, E08.3523, E08.3529, E08.3531, E08.3532, E08.3533, E08.3539 E08.3541, E08.3542, E08.3543, E08.3549, E08.3551, E08.3552, E08.3553, E08.3559, E08.3591, E08.3592, E08.3593, E08.3599, E08.37X1, E08.37X2, E08.37X3, E08.37X9, E09.3211, E09.3212, E09.3213, E09.3219, E09.3291, E09.3292, E09.3293, E09.3299, E09.3311, E09.3312, E09.3313, E09.3319, E09.3391, E09.3392, E09.3393, E09.3399, E09.3411, E09.3412, E09.3413, E09.3419, E09.3491, E09.3492, E09.3493, E09.3499, E09.3511, E09.3512, E09.3513, E09.3519, E09.3521, E09.3522, E09.3523, E09.3529, E09.3531, E09.3532, E09.3533, E09.3539, E09.3541, E09.3542, E09.3543, E09.3549, E09.3551, E09.3552, E09.3553, E09.3559, E09.3591, E09.3592, E09.3593, E09.3599, E09.37X1, E09.37X2, E09.37X3, E09.37X9, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.37X1 E10.37X2, E10.37X3, E10.37X9, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531 E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, 13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.37X1, E13.37X2, E13.37X3, E13.37X9, O24.415, O24.425, O24.435.


MA05.015
03/29/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on home blood glucose monitors.
08/19/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on home blood glucose monitors. ICD 10 codes were added to Attachment B of the policy
01/01/2015This is a new policy.





Version Effective Date: 12/29/2017
Version Issued Date: 12/29/2017
Version Reissued Date: 04/25/2018