Covered and Noncovered Services : Diabetic Supplies

Diabetic Equipment

Blood glucose monitoring equipment and supplies are covered when the medically necessary requirements according to Wis. Admin. Code § DHS 101.03(96m), are met:

• The member is under the care of a physician or nurse practitioner.
• The frequency of testing is determined by the physician or nurse practitioner treating the member's diabetes.
• The appropriate documentation is maintained in the member's medical record, and is available to the DHS on request, per Wis. Admin. Code § DHS 106.02(9).

A home blood glucose monitor (a device for monitoring blood sugar values) is covered when all the following conditions are met:

• The member is being treated by a physician or nurse practitioner for diabetes.
• The member's condition is noted in the physician's orders which are maintained on file.
• The member's diabetic equipment and supplies have been ordered by the treating physician or nurse practitioner.
• The member, or the member's caregiver, has completed or is scheduled to begin training on how to use the equipment.
• The member, or the member's caregiver, is capable of using the test results to verify the member's glycemic control.

Prescriber's Orders

The physician or nurse practitioner treating the member's diabetes must include the following information on an order:

• The items, supplies, and accessories needed
• The quantities to be dispensed
• The frequency of use

In addition, the provider is responsible for documenting the diagnosis (ICD code or narrative) of diabetes. The provider is also responsible for documenting the source of this information, for example, the prescriber or the patient.

Other requirements and limitations for the prescriber's orders for diabetic equipment and supplies include:

• The order is valid for up to 12 months must be renewed with new written orders by the treating physician or nurse practitioner.
• For continued coverage of test strips and lancets, the treating physician or nurse practitioner, the member, or the member's caregiver must initiate the renewal order. A supplier may not initiate the renewal order for these items.
• The renewal order must contain the same information as described above for prescriber's orders.
• An initial or renewal order for supplies and equipment "as needed" is not valid.

Modifiers for Diabetic Equipment

When submitting claims to ForwardHealth follow these procedures:

• Enter one of the following modifiers in Item Number 24D of the 1500 Health Insurance Claim Form for each procedure code billed:
  • "KS": Non-insulin treated diabetes member. (Type II diabetes)
  • "KX": Insulin-treated diabetes member. (Type I diabetes)
• Include the ICD diagnosis code describing the condition that necessitates glucose testing in Item Number 24E of the 1500 Health Insurance Claim Form for each procedure code indicated.

Preferred Products

Certain diabetic supplies have preferred products and non-preferred products. Non-preferred products require PA for members enrolled in BadgerCare Plus and Wisconsin Medicaid. The following preferred and non-preferred diabetic supplies also have quantity limits:

• Blood glucose meters
• Blood glucose test strips

Not all blood glucose meters and blood glucose test strips provided by a preferred manufacturer are preferred products. For a complete list of preferred and non-preferred diabetic supplies, providers may refer to the Diabetic Supply List Quick Reference.

The following diabetic supplies are reimbursable by NDC:

• Blood glucose calibrator solutions and chips
• Blood glucose meters
• Blood glucose test strips
• Insulin syringes
• Lancets
• Lancet devices
• Pen needles

Quantity Limits

Certain diabetic supplies have quantity limits.

Providers may dispense up to the allowed quantity to members but may not exceed the quantity limit without requesting a quantity limit override. To request an override of quantity limits for diabetic supplies, providers may contact the DAPO Center.

For type I diabetics, the following are examples of when providers may request a quantity limit policy override for diabetic supplies:

• If the member is an uncontrolled type 1 diabetic with episodes of hypoglycemia and is being treated by an endocrinologist or has been referred to the primary care provider by an endocrinologist
• If the member is using an insulin pump

For type II diabetics, providers may request a quantity limit policy override for diabetic supplies, for example, when the member is using sliding scale insulin and the override is medically warranted. Requests for quantity limit policy overrides for type II diabetics will not be granted unless there is sufficient medical evidence to warrant the override.

Providers may request a quantity limit policy override for members, regardless of their benefit plan. If a quantity limit exception is not approved, the service is considered noncovered, and there are no appeal rights due to service limitation policy.