ࡱ> i 2bjbj 4X{b{b* TTTTThhhhd4haZZZZZ5|i@>a@a@a@a@a@a@a$icfPdaT55daTTZZya'''TZTZ>a'>a''2Wf\Z)C Y.*aa0aYog=!.og\f\f\dogT\`'dadak$.aog B : Diabetic Equipment & Supplies HYPERLINK "http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_137531" \l "diab01_01"Revised: January 1, 2022  HYPERLINK \l "Overview" Overview  HYPERLINK \l "ep" Eligible Providers HYPERLINK \l "er"Eligible Members  HYPERLINK \l "cs" Covered Services  HYPERLINK \l "ncs" Noncovered Services  HYPERLINK \l "auth" Authorization  HYPERLINK \l "bill" Billing Overview Diabetic equipment and supplies are used to monitor and control blood glucose levels. Point of Sale Diabetic Testing Supply program The following supplies are included in the diabetic testing supply program: Blood Glucose Monitors (E0607) Therapeutic Continuous Glucose Monitoring (K0553 and K0554) Blood Glucose Test Strips (A4252) Refer to the  HYPERLINK "https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_008992" pharmacy page for  HYPERLINK "https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_181541" Point of Sale Diabetic Testing Supply Program for additional information. These are only covered as a durable medical equipment benefit when billed as a Medicare crossover claim. Eligible Providers Providers may be eligible to dispense blood glucose testing supplies or other diabetic equipment and supplies. Eligible providers must meet criteria for third-party liability (TPL) insurance or Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer. TPL and Medicare Providers must meet any provider criteria, including accreditation, for TPL insurance or Medicare, to assist members for whom MHCP is not the primary payer. Eligible Members MHCP members with diabetes or a related condition are eligible when criteria for specific equipment listed under Covered Services are met. Covered Services Refer to the HYPERLINK "https://mn.gov/dhs/assets/medical-supply-coverage-guide_tcm1053-293319.pdf" \t "_blank"Medical Supply Coverage Guide (PDF) for coverage information and limits on diabetes supplies not specified in this section. The Medical Supply Coverage Guide is also available in an HYPERLINK "https://mn.gov/dhs/assets/medical-supply-coverage-guide_tcm1053-293323.xls"Excel format. Blood Glucose Monitors Codes: E2100, E2101 E2100 (blood glucose monitor with integrated voice synthesizer) or E2101 (blood glucose monitor with integrated lancing/blood sample) may be rented or purchased. Authorization is always required for E2100 and E2101. Criteria For all blood glucose monitors, the member must have a diagnosis that requires regular monitoring of blood glucose levels. The pharmacy or medical suppliers office must keep a written physicians order stating need. E2100 (blood glucose monitor with integrated voice synthesizer) Covered for members with a visual impairment that affects their ability to use a standard glucose monitor. The member must be able to use this device independently. E2101 (blood glucose monitor with integrated lancing/blood sample) Covered for members who have deficits with their dexterity that affect their ability to use a standard glucose monitor. The member must be able to use this device independently. Continuous Blood Glucose Monitoring (CGM) Codes: A9276-A9278 (Adjunctive CGM) Adjunctive CGM systems Adjunctive continuous glucose monitoring does not replace traditional home blood glucose monitoring for making treatment decisions, but may be authorized as a warning or alert system for individuals with insulin-dependent diabetes and a history of severe hypoglycemia (less than 50 mg/dL) with unawareness due to age or cognitive function. Documentation must show frequent home glucose monitoring at least six times daily and appropriate modifications to insulin regimen. Members must have a caregiver who can appropriately respond to hypoglycemic episodes. Authorization is always required. Adjunctive CGM systems consist of three components: the sensor, the transmitter and the receiver. The disposable sensor (A9276) is 1 unit = 1-day supply, regardless of how often the sensor is replaced. The transmitter may require replacement between one and four times per year, depending on the system. The receiver is durable medical equipment, and should last three years or more. Adjunctive CGM systems must be coded based on Pricing, Data Analysis and Coding for Medicare, HYPERLINK "https://www4.palmettogba.com/pdac_dmecs/initProductClassificationResults.do" \t "_blank"PDAC. Disposable Blood Glucose Monitor Code: A9275 Disposable blood glucose monitors may be obtained from a medical supply provider or pharmacy. Members who require testing more frequently than is possible with four disposable meters per month may use a traditional meter and test strips. Authorization Authorization is not required. Criteria Disposable blood glucose meters include any necessary test strips and calibration solution or chips Disposable blood glucose meters are limited to four per calendar month Blood glucose test strips may not be billed within 30 days of disposable blood glucose meters Bill one unit per meter with test strips. Submit a claim with an attachment that includes the name of the product dispensed and required documentation for manual pricing. See the Billing Policy section on the HYPERLINK "https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_008993"Equipment and Supplies webpage for documentation requirements. Blood Ketone Test Strips Code: A4252 Blood ketone test strips may be obtained from a medical supply provider or pharmacy. Authorization Authorization is always required. Criteria Member has insulin-dependent diabetes or is on a medically supervised ketogenic diet for intractable seizures Document specific reason blood ketone testing is required, including any history of ketoacidosis or complicating conditions likely to lead to ketoacidosis Specify why urine testing is not sufficient (urine testing is known by DHS to be less accurate, documentation must be clear as to why very accurate results are needed) State frequency of testing and expected duration at this frequency Member must have a blood glucose monitor capable of blood ketone testing. If the member has a blood glucose monitor that is less than five years old, providers must submit a claim with an attachment explaining the need for the replacement monitor with the approved PA for the blood ketone test strips in the notes field Insulin Syringes Code: S8490 Up to 300 insulin syringes per month may be obtained from a medical supply provider or pharmacy. Ambulatory Insulin Infusion Pumps Code: E0784 Insulin infusion pumps may be obtained from a medical supply provider or pharmacy. Authorization Authorization is not required. Criteria Insulin infusion pumps are covered for eligible MHCP members 12 years old or younger with insulin-dependent diabetes, or for eligible MHCP members over age 12 with diabetes who are beta cell autoantibody positive or have a documented fasting serum C-peptide level that is less than or equal to 110 percent of the lower limit of normal of the laboratorys measurement method. Members must meet the following criteria for coverage: Completion of a comprehensive diabetes education program Be on a program of at least three injections of insulin per day, with frequent self-adjustments of dose, for at least six months Documented self-testing an average of at least four times per day Has one of the following: Elevated glycosylated hemoglobin level of HbA1c greater than 7% History of recurring hypoglycemia less than 60 mg/dL Wide fluctuations in blood glucose before mealtime Dawn phenomenon with fasting blood sugars often over 200 mg/dL History of wide glycemic excursions Otherwise unable to maintain optimal control When dispensing a replacement pump for a member with an existing pump, document the date the current pumps warranty expires and the reason for replacement. External Ambulatory Insulin Infusion Systems Code: A9274 External ambulatory infusion pumps may be obtained from a medical supply provider or pharmacy. Authorization Authorization is always required. Criteria External ambulatory insulin infusion systems are covered for eligible MHCP members according to each devices FDA approval criteria. Members must meet the criteria under ambulatory insulin infusion pumps Documentation submitted for authorization must address why an ambulatory insulin infusion pump is not meeting the members needs and why a tubeless option is required for medical necessity. Sharps Disposal Containers Members who self-administer medications using syringes may receive sharps disposal containers. Bill using A4211 and modifier U3 along with appropriate pricing information as outlined under the Billing Policy section on the HYPERLINK "https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_008993"Equipment and Supplies webpage. Submit a pricing attachment for all claims. When billing for members with Medicare, include an attachment that clearly states sharps container not covered by Medicare or add this statement under claim note field in MNITS. Noncovered Services The following supplies are not covered under this durable medical equipment policy but are covered in the point of sale diabetic testing supply program (unless the member has Medicare Part B): Blood Glucose Monitors (E0607) Blood Glucose Test Strips (A4253) Therapeutic Continuous Glucose Monitoring (K0553 and K0554) Please refer to the HYPERLINK "https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_008992"Pharmacy Services section of the MHCP Provider Manual for additional information. Authorization For services that continue to be billed using HCPCS Level II codes, submit authorization requests to KEPRO following instructions in HYPERLINK "http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_008925"Authorization. For services that are part of the pharmacy point of sale benefit, submit authorizations to HID following instructions in HYPERLINK "http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_156475"Drug Authorizations. 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