Diabetic Equipment & Supplies

Revised: 12-30-2009 
 

• Overview
• Eligible Providers
• Covered Services
• Eligible Recipients
• Authorization
• Billing

Overview

Diabetic equipment and supplies are used to monitor and control blood glucose levels.

Eligible Providers

The following providers may provide diabetic equipment and supplies:

• Medical suppliers
• Pharmacies
• Home health agencies
• Indian Health Services
• Federally Qualified Health Center
• Rural Health Clinic

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TPL and Medicare

Providers must meet any provider criteria, including accreditation, for third party insurance (TPL) or Medicare, in order to assist recipients for whom MHCP is not the primary payer.

Eligible Recipients

MHCP recipients with Type 1, Type 2 or Gestational diabetes.

Covered Services

Refer to the Benefits Code Guide and the Medical Supply Coverage Guide (PDF) for coverage information and limits on Diabetes Supplies not specified here. The Medical Supply Coverage Guide is also available in an Excel format.

Blood Glucose Monitors

Codes: E0607, E2100, E2101 
 

The recipient must be diabetic (Type 1, Type 2, or Gestational). A written physician’s order for use to monitor diabetes must be kept in the recipient’s file at the medical supplier’s office. 
 

E0607 (home blood glucose monitor) is purchase only.  
 

Authorization is not required. One monitor is allowed every 5 years. If more than allowed quantity is medically necessary, providers must submit a claim with an attachment explaining circumstances. 
 

E2100 (blood glucose monitor with integrated voice synthesizer) is rent or purchase. 
 

Authorization is always required.

Blood glucose monitors with voice synthesizer are covered for recipients with a severe visual impairment. The visual impairment must be significant enough to make accurate use of a standard blood glucose monitor impossible. The recipient must be able to independently use the blood glucose monitor with voice synthesizer. 
 

E2101 (Blood glucose monitor with integrated lancing/blood sample) is rent or purchase. 
 

Authorization is always required.

Blood glucose monitors with integrated lancing are covered for recipients with impairment of manual dexterity. The dexterity impairment must be significant enough to make accurate use of a standard blood glucose monitor impossible. The recipient must be able to independently use the blood glucose monitor with integrated lancing.

Continuous Blood Glucose Monitoring

Code: A9276-A9278 
 

Authorization

Authorization is always required. 
 

Criteria

Continuous glucose monitoring does not replace traditional home blood glucose monitoring, but may be approved as an adjunct for individuals with type 1 diabetes with a history of severe hypoglycemia less than 50 mg/dL with unawareness due to age or cognitive function. Documentation must show frequent self-monitoring and appropriate modifications to insulin regimen.

Disposable Blood Glucose Monitor

Code: A9275 
 

Authorization

Authorization is not required.

Recipients who require testing more frequently than is possible with 4 disposable meters per month may use a traditional meter/test strips and request authorization for excess quantities of test strips. 
 

Criteria

• Disposable blood glucose meters include any necessary test strips and calibration solution/chips
• Disposable blood glucose meters are limited to 4 per calendar month
• Blood glucose test strips may not be billed within 30 days of disposable blood glucose meters

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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 for documentation requirements.

Blood Glucose Test Strips

Code: A4253 
 

Authorization

Authorization is required for quantities exceeding 4 boxes (200 test strips) per month.  
 

Criteria

Authorization for additional test strips may be approved if recipient needs frequent testing to determine optimal treatment in the following situations:

• Recently diagnosed with diabetes. Higher quantities will be approved for up to 12 months following diagnosis
• Pregnant and has either preexisting diabetes or a diagnosis of gestational diabetes. Higher quantities will be approved through 2 months post partum
• Recently received an ambulatory insulin infusion pump. Authorization for higher quantities may be requested following authorization for the insulin pump. Higher quantities will be approved for up to 6 months
• A history of unstable blood glucose levels and frequently documents blood glucose levels. Higher quantities will be approved for up to 6 months
• Recently documented HbA1c levels greater than 9. Higher quantities will be approved for up to 6 months
• Undergoing adjustments to medications. Higher quantities will be approved for up to 3 months
• History of wide glycemic excursions and lacks the capacity to self-diagnosis or report episodes of hypoglycemia due to age or cognitive functioning. Higher quantities will be approved for up to 12 months.

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Bill one unit per 50 test strips.

Blood Ketone Test Strips

Code: A4252 
 

Authorization

Authorization is always required.  
 

Criteria

• Recipient has insulin dependent Type I diabetes
• 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
• Recipient must have a blood glucose monitor capable of blood ketone testing. If the recipient has a blood glucose monitor that is less than 5 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

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Insulin Syringes

Code: S8490 
 

Authorization

Authorization is required for quantities exceeding 4 boxes (400 syringes) per month. Submit MHCP Authorization form to CDMI. 
 

Criteria

Authorization for additional syringes may be granted if additional injections are needed to achieve optimal control of blood glucose levels.

Reusable Insulin Pens

Code: S5560-S5561 
 

Authorization

Authorization is required if the submitted charge is over $50. 
 

Criteria

Reusable insulin pens are covered for recipients who self-administer insulin, but who are unable to accurately administer insulin using a syringe and vial.

Ambulatory Insulin Infusion Pumps

Code: E0784 
 

Authorization

Authorization is always required. 
 

Criteria

Insulin infusion pumps are covered for eligible MHCP recipients age 12 or younger with type 1 diabetes, or for eligible MHCP recipients 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% of the lower limit of normal of the laboratory’s measurement method. Recipients must meet the following criteria for coverage:

• Completion of a comprehensive diabetes education program
• On a program of at least 3 injections of insulin per day, with frequent self-adjustments of dose, for at least 6 months
• Documented self-testing an average of at least 4 times per day
• Has one of the following:
• Elevated glycosylated hemoglobin level of HbA1c greater than 7.0%
• 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

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When requesting a replacement pump authorization for a recipient with an existing pump, include the date the current pump’s warranty expires.

Authorization

Submit authorization requests through MN–ITS (authorization request 278). Fax the MN–ITS response with the required documentation and physician’s order to CDMI at 651-662-7459. Document the MN–ITS Authorization Request number assigned on every page of each document. 
 

For paper authorization, fax or mail CDMI the required documentation, physician’s orders and the completed MHCP Authorization Form.

Billing

• Use MN–ITS 837P Professional
• Report the referring provider in the Other Provider Types section of the MN–ITS Interactive claim
• Bill services approved through the authorization process on a separate claim from services not requiring authorization.  Example: submit one claim (no authorization required) for the number of units up to the authorization threshold. Submit another claim with the prior authorization number for the additional quantity dispensed over the threshold.
• If the recipient has Medicare, MHCP will pay the deductible/co-insurance on any units for which Medicare made payment Any units for which Medicare denies payment must meet MHCP quantity and authorization requirements. Authorization can be retroactively requested.
• The KL modifier must be used with certain diabetic supplies that are remotely ordered (i.e., by phone, e-mail, internet or mail) and delivered to the recipient’s home by common carriers (e.g., U.S. postal service, Federal Express, UPS, etc.).  The KL modifier must not be used with diabetic supplies obtained by recipients in person from a provider’s place of business. Follow Medicare guidelines for use of the KL modifier. Supplies requiring the KL modifier are: A4233-A4236, A4253, A4256, A4258 and A4259.
• Effective for dates of service on or after 7/1/09, rates for claims using the KL modifier will be based on the lower of the submitted charge or the Medicare feel schedule rate for claims with the KL modifier.
• Shipping costs are included in the MHCP maximum allowable payment and may not be separately billed to MHCP or the recipient.

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