Commercial

Medical Policy

Notification

Outpatient Diabetes Education and Self-Management Training

Notification Issue Date:

This version of the policy will become effective 08/31/2020. This policy has been updated to clarify current benefit criteria and Company case management programs.

The following exception to provider eligibility criteria has been deleted from this policy:

The Company considers diabetes education and self-management training performed in the home setting by a home health agency to be an integral part of the home care visit and is, therefore, not eligible for separate reimbursement consideration. For information regarding diabetes education and self-management training performed in the home setting for individuals with gestational diabetes, please contact the Company's Maternal Case Management Program.

The following qualifying diabetes diagnoses have been deleted from this policy because the diagnoses fall under Type 1 and Type 2 diabetes mellitus:

Diabetes mellitus; juvenile diabetes
Insulin-dependent diabetes mellitus (IDDM)
Non-insulin-dependent diabetes mellitus (NIDDM)
Maternal diabetes mellitus

The following CPT codes have been deleted from this policy:
98960, 98961, 98962, 99078

Title:

Outpatient Diabetes Education and Self-Management Training

Policy #:

12.05.01j

Policy

State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

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.

Outpatient diabetes education and self-management training is covered and eligible for reimbursement consideration by the Company when all of the following requirements are met:

The training is performed in one of the following settings:
- Hospital outpatient
- Outpatient freestanding program
- Professional provider office
The education and training is provided by one of the following:
- A Company-contracted, outpatient diabetes education program (either hospital-based or freestanding) that is recognized by the state Department of Health or the American Diabetes Association as meeting the National Standards for Diabetes Patient Education Programs established by the National Diabetes Advisory Board.
- A certified diabetes educator (CDE) who is practicing in a participating professional provider office.
The individual is diagnosed with diabetes, as identified by one of the following:
- Type I diabetes mellitus
- Type II diabetes mellitus
- Gestational diabetes (insulin- or non-insulin-dependent)
- Abnormal maternal glucose tolerance
- Neonatal diabetes mellitus
The education and training is provided to the individual upon any of the following:
- The initial diagnosis of diabetes
- A significant change in the individual’s diabetes-related symptoms or condition
- The introduction of a new medication or therapy in the treatment or management of the individual’s diabetes

Services that do not meet the requirements in this policy or those that exceed the product and/or state benefit limitations are not eligible for reimbursement by the Company.

REQUIRED DOCUMENTATION

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 professional provider'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

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, outpatient diabetes education and self-management training is covered under the medical benefits of the Company’s products.

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.

BILLING GUIDELINES

At times, it may be necessary to allow a parent, guardian, or significant other of the individual diagnosed with diabetes to attend outpatient diabetes education and self-management training. In such cases, professional providers should report the diabetes education and self-management training services on the claim form for the individual diagnosed with diabetes, regardless of who attends the program.

Description

Outpatient diabetes education and self-management training is a formalized, comprehensive outpatient program that teaches individuals who have been diagnosed with diabetes about their diagnosis and its treatment. Components of such programs include, but are not limited to:

Blood glucose self-monitoring
Dietary requirements
Exercise and its role in the management of diabetes
If necessary, instruction on the self-administration of pharmaceutical agents for the treatment of diabetes

Outpatient diabetes education and self-management training is performed by a professional provider who is certified by the National Certification Board for Diabetes Educators (NCBDE) as a certified diabetes educator (CDE). A diabetes educator is defined under state requirements as a professional who is licensed, certified, or registered to provide diabetes education in the state where the services are performed.

References

American Diabetes Association. Standards of medical care in diabetes--2009. Diabetes Care(serial online). 2009;32:S13-S61. [Diabetes Care Web site]. Available at: http://care.diabetesjournals.org/content/32/Supplement_1/S13.full.pdf+html?sid=f2d1ac68-b09b-438e-95be-f132dc2e5dbf. Accessed March 24, 2020.

Centers for Medicare & Medicaid Services (CMS). Coverage Issues Manual. Part 80: Patient education programs. §80-2: Outpatient diabetic education programs. [CMS Web site]. September 2004. Available at: http://www.cms.hhs.gov/manuals/downloads/Pub06_PART_70.pdf. Accessed March 24, 2020.

Company Benefit Contracts.

Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care(serial online). 2009;32:S87-S94. [Diabetes Care Web site]. Available at: http://care.diabetesjournals.org/content/32/Supplement_1/S87.full.pdf+html?sid=383bcb1b-7573-403d-9541-98f062e2c19b. Accessed March 24, 2020.

General Assembly of Pennsylvania. PA Insurance Company Law of 1921. Act 98 of 1998. H656;§633: Reimbursement for diabetic supplies. [Pennsylvania General Assembly Web site]. 10/16/98. Available at: https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=1998&sessInd=0&act=98. Accessed March 24, 2020.

National Certification Board for Diabetes Educators (NCBDE). Eligibility requirements. [NCBDE Web site]. Available at: http://www.ncbde.org/certification_info/eligibility-requirements. Accessed March 24, 2020.

New Jersey Legislature. NJ Permanent Statutes. Title 17:48-6n: Coverage for diabetes treatment by individual, group hospital service corporation. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed March 24, 2020.

New Jersey Legislature. NJ Permanent Statutes. Title 17:48A-7l: Coverage for diabetes treatment by individual, group medical service corporation. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed March 24, 2020.

New Jersey Legislature. NJ Permanent Statutes. Title 17:48E-35.11: Coverage for diabetes treatment by individual group health service corporation. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed March 24, 2020.

New Jersey Legislature. NJ Permanent Statutes. Title 17B:26-2.1l: Coverage for diabetes treatment by individual health insurance policy. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed March 24, 2020

New Jersey Legislature. NJ Permanent Statutes. Title 17B:27-46.1m: Coverage for diabetes treatment by group health insurance policy. [New Jersey Legislature Web site]. Original: 1995. (Revised: 2001). Available at: http://www.njleg.state.nj.us/. Accessed March 24, 2020.

New Jersey Legislature. NJ Permanent Statutes. Title 26:2J-4.11: Coverage for diabetes treatment by HMO contracts. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed March 24, 2020.

US Department of Health & Human Services. Your Medicare Coverage.Diabetic supplies & services. [Medicare.gov Web site]. Available at: https://www.medicare.gov/Pubs/pdf/11022-LE-Medicare-Coverage-of-Diabetes.pdf. Accessed March 24, 2020.

US Department of Health & Human Services. Your Medicare Coverage.Diabetes self-management training. [Medicare.gov Web site]. Available at: http://www.medicare.gov/coverage/diabetes-self-mgmt-training.html. Accessed March 24, 2020.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachments A, B, and C.

HCPCS Level II Code Number(s)

G0108 Diabetes outpatient self-management training services, individual, per 30 minutes

G0109 Diabetes outpatient self-management training services, group session (two or more), per 30 minutes

S9140 Diabetic management program, follow-up visit to non-MD provider

S9141 Diabetic management program, follow-up visit to MD provider

S9455 Diabetic management program, group session

S9460 Diabetic management program, nurse visit

S9465 Diabetic management program, dietitian visit

Revenue Code Number(s)

0942 Education/Training

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 12.05.01j:

11/26/2025

The policy has been reviewed and reissued to communicate the Company’s continuing position on Outpatient Diabetes Education and Self-Management Training.

10/26/2020

This version of the policy will become effective 10/26/2020. This policy has been updated to clarify current benefit criteria and Company case management programs.

The following exception to provider eligibility criteria has been deleted from this policy:

The Company considers diabetes education and self-management training performed in the home setting by a home health agency to be an integral part of the home care visit and is, therefore, not eligible for separate reimbursement consideration. For information regarding diabetes education and self-management training performed in the home setting for individuals with gestational diabetes, please contact the Company's Maternal Case Management Program.

The following qualifying diabetes diagnoses have been

deleted

from this policy because the diagnoses fall under Type 1 and Type 2 diabetes mellitus:

Diabetes mellitus; juvenile diabetes

Insulin-dependent diabetes mellitus (IDDM)

Non-insulin-dependent diabetes mellitus (NIDDM) Maternal diabetes mellitus

The following CPT codes have been deleted from this policy:

98960, 98961, 98962, 99078

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

Version Effective Date:

10/26/2020

Version Issued Date:

10/26/2020

Version Reissued Date:

11/26/2025