Loading...Loading...Policy No: 128
Date of Origin: 07/01/2022
Section: Administrative
Last Reviewed: 10/01/2022
Last Revised:
Approved: 10/13/2022
Effective: 01/01/2023
This policy applies only to physicians and other qualified health care professionals, including Durable Medical Equipment (DME) providers.
Glucose Monitor
A medical device for determining the approximate concentration of glucose in the blood.
Note: This policy is not effective until 1/1/2023. To view the current policy, click here
This policy applies only to the supplies/accessories used with glucose monitors.
Supplies/accessories used with a glucose monitor may be covered when criteria for the monitor are met. Our health plan utilizes Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCD) to determine the reasonable and necessary maximum quantities and frequencies for diabetic supply purchases. Our health plan reserves the right to assign a maximum limit to codes not included in CMS guidelines.
When the total units of service for a Healthcare Common Procedure Coding System (HCPCS) code have exceeded the maximum allowed within the specified time frame, our health plan will allow up to that limit and deny the remaining units. Our health plan will allow up to a 10-day grace period.
Example: Fifteen (15) units of HCPCS A4253 are purchased on 9/1/2022. The member may receive up to three (3) additional units of HCPCS A4253 prior to 12/31/2022, for a total of eighteen (18) units of HCPCS A4253 purchased within a 3 month/90 day period.
HCPCS Code | Code Description | Maximum Units | Frequency |
A4253 | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips | 18 | 3 months/90 days |
A4258 | Spring-powered device for lancet, each | 2 | 1 year/365 days |
K0553 | Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service | 3 | 3 months/90 days |
K0554 | Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system | 1 | 5 years/1825 days |
The maximum units for K0553 are based on the code definitions and are included in the table for clarity.
We recognize that previously listed codes A4210, A4230, A4231, A4257, A9276, A9277, A9278 are active HCPCS Codes, however they are all non-reimbursable or Status Indicator N for CMS.
Center for Medicare & Medicaid Services (CMS) Local Coverage Determination (LCD), L33822
Noridian Healthcare Solutions, Reasonable Useful Lifetime- Clarification. Reasonable Useful Lifetime
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.