Glucose Monitoring Supplies

Affected Providers

Treating practitioners and DME suppliers who bill for glucose monitors and diabetic accessories and supplies.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Glucose Monitors (L33822) has the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for glucose monitors is 25.2%, with a projected improper payment amount of $278.5 million.

We cover home blood glucose monitors (BGMs), adjunctive and non-adjunctive continuous glucose monitors (CGMs), and diabetic accessories and supplies under the DME benefit. You must meet the provisions in National Coverage Determination (NCD): Home Blood Glucose Monitors (40.2) and LCD L33822.

Denial Reasons

No documentation accounted for 67.6% of improper payments for glucose monitors during the 2024 reporting period, while insufficient documentation (26.6%) and other errors (5.8%) also caused improper payments.

Denials for diabetic testing strips are due to suppliers submitting claims with at least 1 of these errors:

• Lacking a documented diagnosis code for diabetes
• Overlapping with an inpatient hospital stay
• Overlapping with a skilled nursing facility stay

Preventing Denials

Home Blood Glucose Monitors

To be eligible for coverage of home BGM and related accessories and supplies, the patient must meet both these basic criteria:

1. The patient has diabetes (find the ICD-10 Diagnosis Codes that Support Medical Necessity section in Article: Glucose Monitor (A52464))
2. The patient’s treating practitioner shows that the patient, or their caregiver, has enough training to use the device prescribed by providing a prescription for the appropriate supplies and frequency of blood glucose testing

For all glucose monitors and related accessories and supplies, if the patient doesn’t meet the basic coverage criteria, we deny items as not reasonable and necessary.

When we cover a glucose monitor, we also cover these supplies billed by their HCPCS codes: 

• Lancets (A4259),
• Blood glucose test reagent strips (A4253),
• Glucose control solutions (A4256)
• Spring-powered devices for lancets (A4258).

More than 1 spring-powered device (code A4258) per 6 months isn’t reasonable and necessary.

Usual Utilization (Applies to BGM Only)

• Patients not being treated with insulin have coverage for up to 100 test strips and up to 100 lancets every 3 months if they meet the basic coverage criteria
• Patients being treated with insulin have coverage for up to 300 test strips and up to 300 lancets every 3 months if they meet basic coverage criteria

High Utilization (Applies to BGM Only)

• Patients not being treated with insulin have coverage for more than 100 test strips and more than 100 lancets every 3 months if criteria a – c are met
• Patients being treated with insulin have coverage for more than 300 test strips and more than 300 lancets every 3 months if they and their provider meet all criteria a – c
  1. The patient meets basic coverage criteria (1–2 in the Home Blood Glucose Monitors section) for all home glucose monitors and related accessories and supplies
  2. Within the 6 months before ordering strips and lancets that exceed utilization guidelines, the treating practitioner has an in-person or Medicare-approved telehealth visit with the patient to evaluate their diabetes control and need for the specific quantity of supplies
  3. Every 6 months, for continued dispensing of quantities of testing supplies that exceed the usual utilization amounts, the treating practitioner verifies adherence to the high utilization testing regimen

If the patient doesn’t meet basic coverage criteria (1–2), we deny all testing supplies as not reasonable and necessary. If you provide quantities of test strips or lancets that exceed utilization guidelines and you don’t meet criteria a – c, we deny the excess amount as not reasonable and necessary.

Continuous Glucose Monitor Coverage Indications

A non-adjunctive CGM can be used to make treatment decisions without needing a stand-alone BGM to confirm testing results. An adjunctive CGM requires that the user verify their glucose levels or trends displayed on a CGM with a BGM before making treatment decisions. We may classify both non-adjunctive and adjunctive CGMs as DME.

To be eligible for coverage of a CGM and related supplies, the patient must meet all these initial coverage criteria:

1. The patient has diabetes mellitus (find the ICD-10 Diagnosis Codes that Support Medical Necessity section in Article A52464)
2. By providing a prescription, the patient’s treating practitioner shows that the patient, or their caregiver, has enough training to use the CGM prescribed
3. The physician prescribes the CGM under its FDA indications for use
4. The patient, who has a prescription for the CGM to improve glycemic control, meets at least 1 of the criteria below:
   1. Is insulin-treated
   2. Has a history of problematic hypoglycemia with documentation of at least 1 of the following (see LCD L33822):
      • Recurrent (more than 1) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple attempts to adjust medications or change the diabetes treatment plan
      • A history of 1 level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental or physical state requiring third-party assistance for treatment of hypoglycemia
5. Six months before ordering the CGM, the treating practitioner has an in-person or Medicare-approved telehealth visit with the patient to evaluate their diabetes control and finds they meet criteria 1–4 above.

Continuous Glucose Monitor Coverage Guidelines

Every 6 months the treating practitioner must conduct an in-person or Medicare-approved telehealth visit with the patient. Document the patient’s adherence to their CGM regimen and diabetes treatment and make sure that the supplies remain medically necessary.

In cases where we didn’t originally pay for the CGM device, you must meet all coverage, coding, and documentation requirements in effect for the date of service on the claim under review.

A supplier doesn’t have to deliver supplies used with a CGM every month to bill HCPCS code A4238 or A4239 every month.

• To bill code A4238 or A4239, the supplier must have previously delivered 1 full month (30 days) quantities of supplies following the date of service on the claim, and they must check supplies
• Suppliers may continue billing for code A4238 or A4239 monthly if enough supplies remain to last for 1 full month (30 days)
• If there aren’t enough supplies to last for 1 full month (30 days), the supplier must provide more supplies before billing the supply allowance
• Suppliers may dispense and bill their DME Medicare Administrative Contractor (MAC) for up to a 90-day supply

Refill Requirements

For DMEPOS items and supplies provided on a recurring basis, base your billing on prospective, not retrospective use.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Medical Necessity for Diabetic Accessories & Supplies (Including Glucose Monitors)

A supplier bills a claim for HCPCS code E2102 (Adjunctive, non-implanted continuous glucose monitor or receiver) and submits the medical record per the review contractor’s request. The date in the medical record indicates it’s been 8 months since the last in-person or Medicare-approved telehealth visit with the patient to document adherence to their CGM regimen and diabetes treatment plan.

What Documentation Was Missing?

The treating practitioner didn’t document an in-person or Medicare-approved telehealth visit with the patient in the last 6 months.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the MAC recoups payment.

Recommendation

To justify continued CGM coverage as reasonable and necessary, the treating practitioner must conduct an in-person or Medicare-approved telehealth visit with the patient every 6 months following the initial prescription to document adherence to their CGM regimen and diabetes treatment plan.