ICD-10-CM Diagnosis Codes
ICD-10-PCS Procedure Codes
CPT® Procedure Codes
HCPCS Supply/DME Codes
ICD-9-CM Diagnosis Codes
Place of Service Codes
UB04 Condition Codes
UB04 Revenue Codes
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.
For some items in this policy to be covered by Medicare, a written order prior to delivery (WOPD) is required. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about WOPD prescription requirements.
To be eligible for coverage of home blood glucose monitors and related accessories and supplies, the beneficiary must meet both of the following basic criteria (1) - (2):
If neither basic coverage criterion (1) or (2) is met, all testing supplies will be denied as not reasonable and necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria (a) - (c) are not met, the amount in excess will be denied as not reasonable and necessary.
- Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and supplies are met; and,
- The treating physician has seen the beneficiary, evaluated their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines and has documented in the beneficiary's medical record the specific reason for the additional materials for that particular beneficiary; and,
- If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician's records (e.g., a specific narrative statement that adequately documents the frequency at which the beneficiary is actually testing or a copy of the beneficiary's log) that the beneficiary is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the beneficiary is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.
CMS Pub. 100-3, (Medicare National Coverage Determinations Manual), Chapter 1, Section 40.2
Contractor Name(Contractor Number) - Contractor Info
National Government Services, Inc. (17003) - DME Region B
The appearance of a code in this section does not necessarily indicate coverage.
EY - No physician or other health care provider order for this item or service.
KS - Glucose monitor supply for diabetic beneficiary not treated by insulin.
KX - Requirements specified in the medical policy have been met
E0607 E0620 E2100 E2101 ACCESSORIES/SUPPLIES A4233 A4234 A4235 A4236 A4244 A4245 A4246 A4247 A4250 A4253 A4255 A4256 A4257 A4258 A4259 A9275 A9276 A9277 A9278
The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on "Coverage Indications, Limitations and/or Medical Necessity" for other coverage criteria and payment information. 249.00 249.01 249.10 249.11 249.20 249.21 249.30 249.31 249.40 249.41 249.50 249.51 249.60 249.61 249.70 249.71 249.80 249.81 249.90 249.91 250.00 250.01 250.02 250.03 250.10 250.11 250.12 250.13 250.20 250.21 250.22 250.23 250.30 250.31 250.32 250.33 250.40 250.41 250.42 250.43 250.50 250.51 250.52 250.53 250.60 250.61 250.62 250.63 250.70 250.71 250.72 250.73 250.80 250.81 250.82 250.83 250.90 250.91 250.92 250.93 648.00 648.01 648.02 648.03 648.04
All ICD-9 codes that are not specified in the previous section.