Applies to members of:

All plans

Definition

A disease in which the body produces too little or no insulin, or insulin is produced but the body can't use it. This results in high levels of sugar in the blood.

Medical policy

• Infusion Services & Equipment – 91414

Also see

• Continuous glucose monitoring
• Drug coverage
• Lab tests
• Medical benefit & DME authorization requests

Medicare authorizations for diabetes testing supplies

To prescribe more than the approved limit of diabetes testing supplies for Medicare Advantage plan members, a Pre-Service Organization Determination (PSOD) is required. A PSOD is equivalent to the Advance Beneficiary Notice (ABN) used by Original Medicare, but under Part C Medicare rules it must be issued by Priority Health.

The provider should document if a member is not insulin dependent.

• Participating providers: Use our online authorizations tool to go to GuidingCare.
• Non-participating providers: Request a PSOD.

Diabetes Self-Management Education and Training (DSMES) program

Authorizations

No authorization is required for payment to participating providers for diabetes education. PCP referral is encouraged.

Billing

Codes covered for all products in outpatient facility and physician office locations:

• G0108, Diabetes outpatient self-management training services, individual, per 30 minutes
• G0109, Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes
• Facilities billing on a UB04, use revenue code 0942 in combination with the CPT/HCPCS codes.

Medical Nutrition Therapy (MNT) provided by a Registered Dietitian can be billed separately for members of most plans. (MNT doesn't necessarily have to be provided during DSMES training.)

Payment

Pays at the full medical benefit. 

Self-funded plans may require a copay or coinsurance instead of paying the full amount. Call the Provider Helpline to verify.

The deductible applies for HSA members.