Retroactively effective to January 1, 2024, in alignment with the CMS expanded model of the Medicare Diabetes Prevention Program (MDPP), this communication is intended to provide updates to the MA00.003z Preventive Care Services policy for MDPP recommendation.
Based on guidance from CMS, Medicare diabetes prevention program preventive coverage was updated to 22 sessions over a one-year period. In accordance with CMS, the following HCPCS codes were removed from this recommendation: G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9882, G9883, G9884, G9885, G9891.
COVERAGE
The Medicare diabetes prevention program (MDPP) is covered as a preventive service for individuals enrolled in a program approved by the Centers for Disease Control and Prevention (CDC) for all sessions when all of the following criteria are met:
- Body Mass Index (BMI) of at least 25 (23 if self-identified as Asian) on the date of the first core session
- Any of the following blood test requirements have been met:
- A hemoglobin A1c test with a value between 5.7% and 6.4%
- A fasting plasma glucose of 110-125 mg/dL
- A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)
- No documented history of diabetes prior to the date of the first core session (with the exception of gestational diabetes)
- No diagnosis of end-stage renal disease (ESRD)
- Member has not previously received diabetes prevention program services
NOTE: Sessions will be covered when performed face-to-face or virtually, e.g., the encounter is not in person.
FREQUENCY
A maximum of 22 MDPP sessions are covered as a preventive service over a one-year period. In accordance with CMS, this benefit is covered once during a member's lifetime. CMS recommends 16 weekly sessions during months 1 through 6, and 6 monthly sessions during months 7 through 12.