Continuous Glucose Monitoring

www.MercyCareAZ.org

April 20, 2021

Applicable to: Mercy Care Complete Care, Mercy Care DD, Mercy Care Long Term Care, Mercy Care RBHA and Mercy Care DCS CHP

A Local Coverage Determination (LCD) for the allowance of payment for Continuous Glucose Monitors (CGM) to all Mercy Care Medicaid programs has been made. This is in accordance with provisions outlined in CMS Pub. 100-03, (Medicare National Coverage Determinations Manual), Chapter 1, Section 40.2, CMS Ruling 1682R.

This applies to the following devices:

Continuous Glucose Monitors (CGM)

Continuous glucose monitoring systems make continuous measurements of glucose levels. Most systems consist of a sensor that is attached to the back of the arm or abdomen. The sensor has a very thin wire that is inserted subcutaneously. The wire measures the glucose level in interstitial fluid that exists between the cells. The sensor is attached to a transmitter that sends the glucose readings to a wireless receiver. The receiver is a small computerized device that records and stores the glucose readings.

Home Blood Glucose Monitors (BGM)

Glucometers used for patients with all types of diabetes mellitus to monitor blood glucose and are available in a variety of models with various features, including digital read-out, memory, result print-out, easy specimen capture, and many others.

Coverage Criteria

CGM devices covered by Mercy Care under the DME benefit are defined in CMS Ruling 1682R as therapeutic CGMs.

Therapeutic CGMs and related supplies are covered by Mercy Care when all of the following coverage criteria (1-6) are met:

The beneficiary has diabetes mellitus; and
The beneficiary has been using a CGM and performing frequent (four or more times a day) testing; and
The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered Continuous Subcutaneous Insulin Infusion (CSII) pump; and
The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and
Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and
Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.

When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered.

If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not reasonable and necessary.

The supply allowance (code K0553) is billed as 1 Unit of Service (UOS) per thirty (30) days. Only one (1) UOS of code K0553 may be billed to Mercy Care at a time. Billing more than 1 UOS per 30 days of code K0553 will be denied as not reasonable and necessary.

Therapeutic CGM devices replace a standard home blood glucose monitor (HCPCS codes E0607, E2100, E2101) and related supplies (HCPCS codes A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259). Claims for a BGM and related supplies, billed in addition to an approved CGM device (code K0554) and associated supply allowance (code K0553), will be denied.

All therapeutic CGM devices billed to Mercy Care using HCPCS code K0554 must be reviewed for correct coding. CGM systems that have not been reviewed and listed on the Product Classification List for HCPCS code K0554 will be denied as incorrect coding.

EQUIPMENT

CODE DESCRIPTION

E0607 - HOME BLOOD GLUCOSE MONITOR
E0620 - SKIN PIERCING DEVICE FOR COLLECTION OF CAPILLARY BLOOD, LASER, EACH
E2100 - BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER
E2101 - BLOOD GLUCOSE MONITOR WITH INTEGRATED LANCING/BLOOD SAMPLE
K0554 - RECEIVER (MONITOR), DEDICATED, FOR USE WITH THERAPEUTIC GLUCOSE CONTINUOUS MONITOR SYSTEM

ACCESSORIES/SUPPLIES

CODE DESCRIPTION

A4233 - REPLACEMENT BATTERY, ALKALINE (OTHER THAN J CELL), FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH
A4234 - REPLACEMENT BATTERY, ALKALINE, J CELL, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH
A4235 - REPLACEMENT BATTERY, LITHIUM, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT,
A4236 - REPLACEMENT BATTERY, SILVER OXIDE, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH
A4244 - ALCOHOL OR PEROXIDE, PER PINT
A4245 - ALCOHOL WIPES, PER BOX
A4246 - BETADINE OR PHISOHEX SOLUTION, PER PINT
A4247 - BETADINE OR IODINE SWABS/WIPES, PER BOX
A4250 - URINE TEST OR REAGENT STRIPS OR TABLETS (100 TABLETS OR STRIPS)
A4253 - BLOOD GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50 STRIPS
A4255 - PLATFORMS FOR HOME BLOOD GLUCOSE MONITOR, 50 PER BOX
A4256 - NORMAL, LOW AND HIGH CALIBRATOR SOLUTION / CHIPS
A4257 - REPLACEMENT LENS SHIELD CARTRIDGE FOR USE WITH LASER SKIN PIERCING DEVICE, EACH
A4258 - SPRING-POWERED DEVICE FOR LANCET, EACH
A4259 - LANCETS, PER BOX OF 100
A9275 - HOME GLUCOSE DISPOSABLE MONITOR, INCLUDES TEST STRIPS
A9276 - SENSOR; INVASIVE (E.G., SUBCUTANEOUS), DISPOSABLE, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY SUPPLY
A9277 - TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM
A9278 - RECEIVER (MONITOR); EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM
K0553 - SUPPLY ALLOWANCE FOR THERAPEUTIC CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE

As always, don't hesitate to contact your Mercy Care Network Management Representativ e with any questions or comments. You can find this notice and all other provider notices on our Mercy Care website.

Thanks for all you do!