TRANSMITTAL #:  127

DATE:  05/16/2011

TRICARE CHANGE #:  N/A

CHAMPVA POLICY MANUAL

CHAPTER: 2

SECTION: 17.10

TITLE: BLOOD GLUCOSE LEVEL MONITOR

AUTHORITY:  38 CFR 17.270(a),17.272(a), and 17.273(e)

RELATED AUTHORITY:  32 CFR 199.4(d)(3)(ii)

I. EFFECTIVE DATE(S)

December 29, 1982

II. PROCEDURE CODE(S)

A.      CPT Codes:  95250-95251

B.      HCPCS Level II Codes:  A9276-A9278, E0607, and S1030-S1031

III. DESCRIPTION(S)

A.      Blood glucose level monitors are reflectance meters designed to precisely measure mg/dl blood glucose level for individual use in self management of diabetes.

B.      A CGMS (Continuous Glucose Monitoring System) is a medical device used to monitor patients with diabetes mellitus.  These devices, which consist of an external receiver, external transmitter, and a subcutaneously placed sensor, monitor diabetic patients by providing the physician and/or patient with periodic measurements of glucose levels in interstitial fluid.  CGMS devices are usually prescribed to diabetic patients whose diabetes is not sufficiently controlled with standard diabetic medical regimens.  These devices are intended only to supplement, not replace, blood glucose readings obtained from standard fingerstick glucose meters and test strips.

IV. POLICY

A.      A blood glucose level reflectance meter monitor is covered as DME (Durable Medical Equipment) when appropriate based on benefit policy and when precise mg/dl blood glucose levels are necessary for diabetes management (see Chapter 2, Section 17.1, DME (Durable Medical Equipment) and Supplies).

B.      Use of blood glucose control devices for short term management of insulin-dependent diabetic patients in times of crisis is covered.  Patients usually undergo this treatment for only 24 to 48 hours.

C.      Documentation must be submitted with the claim which establishes the medical necessity for precise mg/dl level measurement compared to the narrow range mg/dl level measurement of visually read strips.

D.      Documented insulin dependent diabetes in conjunction with chronic renal failure, ongoing dialysis therapy, pregnancy, high renal threshold, insulin reaction, acidosis or vision impairment, need not be routinely referred for clinical review.

E.       FDA approved CGMS devices are covered only when it is documented that the recipient of the device is required to perform at least four self-monitoring blood glucose checks daily and is compliant with recommended medical regimens.

F.       Short-term (up to 72 hour), intermittent (up to six times per year) use of a CGMS device may be covered for type 1 diabetic beneficiaries age seven years and over (or consistent with device labeling) when the beneficiary has completed a comprehensive diabetic education program, there is documentation of appropriate modification in insulin regimen, and the physician documents any one of the following:

1.       Glycosylated hemoglobin level (HBA1c) is greater than 9.0% or less than 4.0%.

2.       History of unexplained large fluctuations in daily glucose values before meals (greater than 150 mg/dl).

3.       History of early morning fasting hyperglycemia (“dawn phenomenon”).

4.       History of severe glycemic excursions.

5.       Hypoglycemic unawareness.

G.      Long-term (greater than seventy-two hour, continuous or periodic) use of a CGMS device (includes transmitter, receiver, and sensors), may be covered for beneficiaries who meet the criteria for short-term use and the ordering physician documents any one or more of the following:

1.       History of recurrent, unexplained, severe hypoglycemic events or hypoglycemic unawareness, that is, blood glucose less than 50 mg/dl).

2.       History of recurrent episodes of ketoacidosis.

3.       Hospitalizations for uncontrolled glucose levels.

4.       Frequent nocturnal hypoglycemia.

5.       The beneficiary is pregnant and has poorly controlled type 1 diabetes or gestational diabetes.

V. EXCLUSION(S)

A.      CGMS devices for patients with type 2 diabetes.

*END OF POLICY*