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Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.05t

Policy

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 the 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.
The quantity of test strips and lancets that are covered depends on the usual medical needs of the diabetic individual according to the following guidelines:
  • Up to 200 test strips and up to 200 lancets per month are covered if the basic coverage criteria above are met.
  • If the quantity dispensed exceeds this, 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 requires 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 presented at least every 6 months.
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, when specific medical policies related to the diagnosis and treatment of diabetes exists, the medical necessity requirements and limitations listed in those policies apply. A list of these policies is provided in the Cross References section of this policy.
​
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, A4236
E2101A4233, A4234, A4235, A4236

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.

STANDARD WRITTEN 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 standard written order at the time of an audit or after an audit for submission as an original standard written 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 durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES ​(WHEN APPLICABLE)
The 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 7 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 5 days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the 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 (e.g., subcutaneously implanted) insulin pump.
  • Injection aids (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 their 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: https://lis.njleg.state.nj.us/nxt/gateway.dll?f=templates&fn=default.htm&vid=Publish:10.1048/Enu. Accessed Septe,ber 17, 2025.


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: https://lis.njleg.state.nj.us/nxt/gateway.dll?f=templates&fn=default.htm&vid=Publish:10.1048/Enu. Accessed September 17, 2025.

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: https://lis.njleg.state.nj.us/nxt/gateway.dll?f=templates&fn=default.htm&vid=Publish:10.1048/Enu. 
Accessed September 17, 2025.

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: https://lis.njleg.state.nj.us/nxt/gateway.dll?f=templates&fn=default.htm&vid=Publish:10.1048/Enu. Accessed September 17, 2025. 

Pennsylvania (PA) Act 98 of 1998. Section 634. Eff 02/12/1999. Available at: 1998 Act 98 - PA General Assembly (state.pa.us). Accessed September 17, 2025. 

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 September 17, 2025.​

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
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

Policy History

Revision From 05.00.05t:
​10/29/2025

​The policy has been reviewed and reissued to communicate the Company’s continuing position on Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes.​
10/01/2025This policy has been identified for the ICD-10 code update, effective 10/01/2025.

​Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

The following ICD-10 code has been added to Attachment A of this policy:

E11.A: Type 2 diabetes mellitus without complications in remission​​


The following HCPCS code has been added to Attachment B of this policy:

J1612 : Injection, glucagon (gvoke), 0.01 mg​​


Revisions From 05.00.05s:
10/01/2024This policy has been identified for the ICD-10 code update, effective 10/01/2024.
​
Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following ICD-10 code narrative has been revised:
Changed from:
A4271 Integrated lancing and blood sample testing cartridges for home blood glucose monitor, per month

Changed to:
A4271 Integrated lancing and blood sample testing cartridges for home blood glucose monitor, per 50 tests​

The following ICD-10 codes have been added to Attachment A (Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes​) of​ this policy:​​
​
E10.A0 Type 1 diabetes mellitus, presymptomatic, unspecified
E10.A1 Type 1 diabetes mellitus, presymptomatic, Stage 1
E10.A2 Type 1 diabetes mellitus, presymptomatic, Stage 2

Revisions From 05.00.05r:
04/01/2024This policy has been identified for the HCPCS code update, effective 04/01/2024.
​
Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

The following HCPCS codes have been added to this policy:​​
​
A4271 Integrated lancing and blood sample testing cartridges for home blood glucose monitor, per month

E2104 Home blood glucose monitor for use with integrated lancing/blood sample testing cartridge​

Revisions From 05.00.05q:
​02/07/2024
​This policy has been reissued in accordance with the Company's annual review process.​​
07/01/2023This policy has been identified for the HCPCS code update, effective 07/01/2023.
​
Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

The following HCPCS codes have been added to this policy:​​
​
J1811 Insulin (fiasp) for administration through dme (i.e., insulin pump) per 50 units

J1812 Insulin (fiasp), per 5 units

J1813 Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50 units

J1814 Insulin (lyumjev), per 5 units​​
​

Revisions From 05.00.05p:
01/01/2023This policy has been identified for the HCPCS code update, effective 01/01/2023.
​
Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

The following HCPCS codes have been termed and removed from this policy:​​
​
​K0553 Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service

K0554 Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system

The following HCPCS codes have been added this policy:

A4239 Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service
​
E2103 Non-adjunctive, non-implanted continuous glucose monitor or receiver

J1611 Injection, glucagon hydrochloride (fresenius kabi), not therapeutically equivalent to j1610, per 1 mg

The following HCPS codes have been revised in this policy:

A4238 Supply allowance for adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service

A9276 Sensor; invasive (e.g., subcutaneous), disposable, for use with non-durable medical equipment interstitial continuous glucose monitoring system, one unit = 1 day supply

​A9277 Transmitter; external, for use with non-durable medical equipment interstitial continuous glucose monitoring system
​
A9278 Receiver (monitor); external, for use with non-durable medical equipment interstitial continuous glucose monitoring system

E2102 Adjunctive, non-implanted continuous glucose monitor or receiver​

Revision From 05.00.05o:
12/05/2022This version of the policy will become effective 12/05/2022. The intent of this policy remains unchanged, however, Face-to-Face requirments have been deleted from the policy section for the following HCPCS code:

  • ​E0607 Home blood glucose monitor​

Revision From 05.00.05n:
04/01/2022This policy has been identified for the HCPCS code update and will become effective 04/01/2022.

The following HCPCS codes have been added to attachment B this policy:

A4238: Supply allowance for adjunctive continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply=1 unit of service

E2102: Adjunctive continuous glucode monitor or receiver​

Revisions From 05.00.05m:
06/02/2021

This policy has been reissued in accordance with the Company's annual review process.​
​10/26/2020
​This version of the policy will become effective 10/26/2020. The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits. Language was incorporated regarding the coverage of and quantity for the following diabetic testing supplies: blood glucose test strips (A4253) and lancets (A4259).

The following HCPCS codes were added to attachment B of this policy (Healthcare Common Procedure Coding System (HCPCS) Codes that Represent Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes):

K0553 Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 Unit of Service

K0554 Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system

S1034 Artificial Pancreas Device System (eg, Low Glucose Suspend [LGS] Feature) Including Continuous Glucose Monitor, Blood Glucose Device, Insulin Pump And Computer Algorithm That Communicates With All Of The Devices

S1035 Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system 

S1036 Transmitter; external, for use with artificial pancreas device system 

S1037 Receiver (monitor); external, for use with artificial pancreas device system

Revisions From 05.00.05l:
01/01/2020This policy has been identified for the HCPCS code update and will become effective 01/01/2020.

The following HCPCS code have been added to attachment B this policy:

A4226 Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week

E0787 External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing

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.
10/1/2025
10/1/2025
10/29/2025
05.00.05
Claim Payment Policy Bulletin
Commercial
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.