Notification



Notification Issue Date:



Claim Payment Policy


Title:Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes

Policy #:05.00.05k

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

Equipment, supplies, and pharmaceuticals that have been approved by the US Food and Drug Administration (FDA) for the treatment of diabetes are covered and eligible for reimbursement consideration by the Company when all of following requirements are met:
  • The group member contract identifies the items as a benefit for the individual.
  • The items are considered medically necessary for the treatment of diabetes.
  • The individual's professional provider prescribes the items for the treatment of diabetes.
  • An eligible provider supplies the items.

Glucose tablets and gels, which are nonprescription (over-the-counter [OTC]) orally administered treatments for acute episodes of hypoglycemia associated with diabetes, are covered and eligible for reimbursement consideration by the Company in products that include benefits for such items.

When diabetes equipment, supplies, and pharmaceuticals are covered, the codes in Attachment B to this policy are eligible for reimbursement consideration as a treatment for diabetes when they are reported with a diagnosis code listed in Attachment A that corresponds to the individual's diabetic condition. However:
  • In addition to this policy, the Company has medical policies on topics related to the diagnosis and treatment of diabetes; a list of these policies is provided in the Cross References section of this policy. The medical necessity requirements and limitations listed in those policies apply.
  • Equipment, supplies, and pharmaceuticals for the treatment of diabetes that are not FDA-approved, or have been determined to be either not medically necessary or experimental/investigational, are not covered and are, therefore, not eligible for reimbursement consideration.

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
E0607A4233, A4234, A4235, A4236
E2100A4233, A4234, A4235, A42 36
E2101A4233, A4234, A4235, A4236

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 items are:

E0607 HOME BLOOD GLUCOSE MONITOR

REQUIRED DOCUMENTATION

EQUIPMENT AND SUPPLIES FOR THE TREATMENT OF DIABETES
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.

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.

PHARMACEUTICALS FOR THE TREATMENT OF DIABETES
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

This policy applies to equipment, supplies, and pharmaceuticals for the treatment of diabetes in general. When there is a Company policy addressing a specific item listed in this policy, refer to the applicable policy. The information in the specific policy takes precedence over this general policy.

Certain diabetes equipment and supplies (e.g., blood glucose meters, test strips, lancets) that are included in a medical benefit may be obtained through a pharmacy. For additional information, contact Member Services or Provider Services.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, equipment, supplies, and pharmaceuticals for the treatment of diabetes are covered under the medical and/or outpatient pharmaceutical benefits of the Company's products.
  • For members without a pharmacy benefit, prescription drugs, such as insulin and oral diabetic agents, may be covered under their medical benefit.

Injectable drugs may be available under more than one benefit category; therefore, individual benefits must be verified. All applicable deductibles, coinsurance, and copayments are the member's responsibility, and the cost to members may vary based on where and how the drug is obtained.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

Description

As used in this policy, diabetes refers to any of the following diagnoses:
  • Diabetes mellitus, juvenile type
  • Diabetes mellitus, type I
  • Diabetes mellitus, type II
  • Insulin-dependent diabetes mellitus (IDDM)
  • Non–insulin-dependent diabetes mellitus (NIDDM)
  • Gestational diabetes (insulin- or non–insulin-dependent)
  • Maternal diabetes mellitus
  • Abnormal maternal glucose tolerance
  • Neonatal diabetes mellitus
  • Secondary diabetes mellitus

EQUIPMENT AND SUPPLIES FOR THE TREATMENT OF DIABETES

Equipment and supplies for the treatment of diabetes are tools that assist an individual with diabetes in managing his/her disease. Examples of these items include, but are not limited to, the following:
  • Blood glucose monitors (also referred to as glucometers, blood glucose meters, or glucose meters)
  • Interstitial continuous glucose monitoring systems (CGMS)
  • Insulin pumps and associated supplies (e.g., infusion sets)
    • The term insulin pump, as used in this policy, refers only to a US Food and Drug Administration (FDA)--approved, externally implanted (i.e., subcutaneously implanted) insulin pump.
  • Injection aides (e.g., air-jet insulin injectors)
  • Alcohol swabs
  • Lancing devices (e.g., lancets, automatic lancing devices, laser skin perforators)
  • Blood and urine test strips (e.g., glucose, ketone)
  • Insulin pens, needles, and syringes for the administration of injectable diabetic medications
  • Glucagon emergency kits (GlucaGen HypoKit)
  • Orthotics and podiatric appliances for the prevention of complications associated with diabetes (see specific policy).

PHARMACEUTICALS FOR THE TREATMENT OF DIABETES

Pharmaceuticals for the treatment of diabetes include both injectable and oral medications that have been approved by the FDA. These pharmaceuticals, which are used by an individual with diabetes for the purpose of attaining and maintaining his/her blood glucose within a medically acceptable range, include the following:
  • Injectable and inhaled pharmaceuticals, examples of which include the following:
    • Insulin, depending on the insulin-type, is an inhaled or injectable prescription or injectable nonprescription (over-the-counter [OTC]) FDA-approved biologic that is administered for the prevention or treatment of hyperglycemia (high blood glucose) associated with diabetes. This insulin is a replacement for or a supplement to an individual's own insulin, which is normally produced by the pancreas.
      • When insulin does not require a prescription, a professional provider directs its dosage and administration.
    • Glucagon, an injectable prescription biologic, is administered for the treatment of hypoglycemia (low blood glucose) associated with diabetes. This glucagon is a replacement for or a supplement to an individual's own glucagon, which is normally produced by the pancreas.
  • Oral medications, examples of which include the following:
    • Alpha-glucosidase inhibitors, biguanides, meglitinides, sulfonylurea drugs, dipeptidyl peptidase-4 inhibitors, and thiazolidinediones are orally administered prescription medications that are designed to maintain blood glucose levels within normal limits via various mechanisms.

Glucose tablets and gels are orally administered nonprescription (OTC) treatments for acute episodes of hypoglycemia associated with diabetes.
  • Although glucose tablets and gels are not prescription medications, a professional provider may direct their dosage and administration.

References


Company Benefit Contracts.

New Jersey (NJ) Permanent Statutes. Title 17:48A-7l. Coverage for diabetes treatment by individual, group medical service corporation. [NJ Legislature Web site]. 01/05/96. Available at: http://www.njleg.state.nj.us/. Accessed March 21, 2018.

New Jersey (NJ) Permanent Statutes. Title 17:48E-35.11. Coverage for diabetes treatment by individual group health service corporation. [NJ Legislature Web site]. 01/05/96. Available at: http://www.njleg.state.nj.us/. Accessed March 21, 2018.

New Jersey (NJ) Permanent Statutes. Title 17B:26-2.11. Coverage for diabetes treatment by HMO contracts. [NJ Legislature Web site]. 01/05/96. Available at: http://www.njleg.state.nj.us/. March 21, 2018.

New Jersey (NJ) Permanent Statutes. Title 17B:27-46.1m. Coverage for diabetes treatment by group health insurance policy. [NJ Legislature Web site]. 01/05/96. Available at: http://www.njleg.state.nj.us/. Accessed March 21, 2018.

Pennsylvania (PA) Act 98 of 1998. Section 634. Eff 02/12/1999.
Available at : http://www.palrb.us/pamphletlaws/19001999/1998/0/act/0098.pdf. Accessed March 21, 2018.

Pennsylvania (PA) General Assembly. PA Insurance Company Law of 1921. Act 98 of 1998. H656;633: Reimbursement for diabetic supplies; signed October 16, 1998. [PA General Assembly Web site]. Available at: http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=1997&sessInd=0&billBody=H&billTyp=B&billNbr=0656&pn=2505. Accessed March 21, 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)

Refer to Attachment A for the applicable ICD-10 codes.


HCPCS Level II Code Number(s)

Refer to Attachment B for a list of Healthcare Common Procedure Coding System (HCPCS) codes that represent equipment, supplies, and pharmaceuticals for the treatment of diabetes.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
Description: ICD 10 Codes

Attachment B: Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
Description: HCPCS Codes



Policy History

REVISIONS FROM 05.00.05k
04/25/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes.

Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 10/01/2017
Version Issued Date: 09/29/2017
Version Reissued Date: 04/25/2018

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.