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Local Coverage Determinations

Medical Review

Medicare Secondary Payer (MSP)

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Home » JB DME » Education » Prescribers » Physicians! Are You Ordering Glucose Monitors and Supplies for Your Patients?

August 25, 2023

Physicians! Are You Ordering Glucose Monitors and Supplies for Your Patients?

The Comprehensive Error Rate Testing (CERT) program has noted a high error rate for glucose monitor claims. The following information is provided to assist you in reducing these types of errors.

Medicare will consider coverage of a glucose monitor and related supplies when your patient's medical record shows they have diabetes and you have determined that your patient or a caregiver is sufficiently trained to use the prescribed device appropriately. (Reference: CMS publication 100-3, Section 40.2.)

Order Requirements

The Standard Written Order (SWO) for the glucose monitor and supplies must include the following:

Patient name or Medicare Beneficiary Identifier (MBI)
Order date
General description of the item (may be a narrative description, a HCPCS code, HCPCS code narrative, or brand name/model number)
For equipment – In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (list each separately)
For supplies – In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (list each separately)
Quantity to be dispensed, if applicable
Treating practitioner's name or NPI
Treating practitioner's signature

Testing Requirements

Medicare will provide coverage for the diabetic testing regimen as outlined in the Glucose Monitors Local Coverage Determination (LCD) (L33822):

Treatment Regimen	Basic Coverage for Test Strips and Lancets	Prescribed Testing Frequency
Insulin treated	Up to 300 per 3 months	Up to 3 times a day
Non-insulin treated	Up to 100 per 3 months	Once a day

For your patients who require additional testing per day, or the quantities of supplies ordered exceeds Medicare's standard utilization parameters, there are some additional documentation requirements that must be met. These are outlined in the Glucose Monitors LCD (L33822):

Basic requirements outlined above have been met; and,
Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, you have had an in-person or Medicare-approved telehealth visit with your patient to evaluate their diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described above; and,
Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual utilization amounts, you must verify adherence to the high utilization testing regimen. The medical record should contain clinical rationale for excess testing as well as any changes to the diabetic treatment plan.(Refer to the CMS "Step-By-Step Guide to Ordering Diabetic Testing Supplies for Medicare Patients Using Home Glucose Monitors")

Continuous Glucose Monitors (CGMs)

A non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone blood glucose monitor (BGM) to confirm testing results. An adjunctive CGM requires the user verify their glucose levels or trends displayed on a CGM with a BGM prior to making treatment decisions. On February 28, 2022, CMS determined that both non-adjunctive and adjunctive CGMs may be classified as DME.

CGMs and related supplies are covered by Medicare when all the following coverage criteria (1-5) are met:

Your patient has diabetes mellitus; and
You have concluded that your patient or their caregiver has sufficient training using the CGM prescribed as evidenced by providing a prescription; and
The CGM is prescribed in accordance with its FDA indications for use; and,
The patient for whom a CGM is being prescribed, to improve glycemic control meets at least one of the criteria:
1. The patient is insulin treated, or
2. The patient has a history of problematic hypoglycemia with documentation of least one of the following:
  – Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persists despite multiple (more than one) attempts to adjust medications(s) and/or modify the diabetes treatment plan;
  
  OR
  
  – A history of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring 3rd party assistance for treatment of hypoglycemia;
Within six (6) months prior to ordering the CGM, you have had an in-person or Medicare-approved telehealth visit with the patient to evaluate their diabetes control and determine criteria (1-4) have been met.

For CGM continued coverage, every six (6) months following the initial prescription of the CGM, you have an in-person visit or Medicare-approved telehealth visit with your patient to assess adherence to their CGM regimen and diabetes treatment plan.

For the in-person or Medicare-approved telehealth treating practitioner visit that is required as part of the ongoing provision of a CGM, there must be sufficient information in the patient's medical record to determine that the patient continues to adhere to their diabetes treatment regimen and use of the CGM device.

For coverage and limitations of these supplies review the Glucose Monitors LCD (L33822) and LCD-related Policy Articles A52464 and A55426

Publication History

August 25, 2023	Added reference "Step-By-Step Guide to Ordering Diabetic Testing Supplies for Medicare Patients Using Home Glucose Monitors"; removed language in regard to therapeutic/non-therapeutic CGM, revised coverage criteria 1-5 for CGMs; added information for CGM continued coverage; added information in regard to the end of the COVID-19 PHE and telehealth visits
July 18, 2022	Added references to Glucose Monitors LCD (L33822), External Infusion Pumps LCD (L33794), and LCD-related Policy Article (A52507); revised the diabetic testing regimen language; added information in regard to treatment with a therapeutic/non-adjunctive CGM and non-therapeutic/adjunctive CGM; changed insulin injections to insulin administrations; removed the four or more times a day testing requirement; added information in regard to non-enforcement directives and waivers associated with the COVID-19 PHE.
July 2020	Revised
November 9, 2018	Originally Published