|
15.2.1.2 Limitations
Glucose monitors are limited as follows:
Prior authorization is not required for glucose monitor procedure codes A9275 and E0607, which are limited to the following diagnosis codes:
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Diagnosis Code
|
Description
|
|
24900
|
Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified
|
|
24901
|
Secondary diabetes mellitus without mention of complication, uncontrolled
|
|
24910
|
Secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or unspecified
|
|
24911
|
Secondary diabetes mellitus with ketoacidosis, uncontrolled
|
|
24920
|
Secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or unspecified
|
|
24921
|
Secondary diabetes mellitus with hyperosmolarity, uncontrolled
|
|
24930
|
Secondary diabetes mellitus with other coma, not stated as uncontrolled, or unspecified
|
|
24931
|
Secondary diabetes mellitus with other coma, uncontrolled
|
|
24940
|
Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled, or unspecified
|
|
24941
|
Secondary diabetes mellitus with renal manifestations, uncontrolled
|
|
24950
|
Secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled, or unspecified
|
|
24951
|
Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled
|
|
24960
|
Secondary diabetes mellitus with neurological manifestations, not stated as uncontrolled, or unspecified
|
|
24961
|
Secondary diabetes mellitus with neurological manifestations, uncontrolled
|
|
24970
|
Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled, or unspecified
|
|
24971
|
Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled
|
|
24980
|
Secondary diabetes mellitus with other specified manifestations, not stated as uncontrolled, or unspecified
|
|
24981
|
Secondary diabetes mellitus with other specified manifestations, uncontrolled
|
|
24990
|
Secondary diabetes mellitus with unspecified complication, not stated as uncontrolled, or unspecified
|
|
24991
|
Secondary diabetes mellitus with unspecified complication, uncontrolled
|
|
25000
|
Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
|
|
25001
|
Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled
|
|
25002
|
Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled
|
|
25003
|
Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled
|
|
25010
|
Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
|
|
25011
|
Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled
|
|
25012
|
Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
|
|
25013
|
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled
|
|
25020
|
Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled
|
|
25021
|
Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled
|
|
25022
|
Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
|
|
25023
|
Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled
|
|
25030
|
Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
|
|
25031
|
Diabetes with other coma, type I [juvenile type], not stated as uncontrolled
|
|
25032
|
Diabetes with other coma, type II or unspecified type, uncontrolled
|
|
25033
|
Diabetes with other coma, type I [juvenile type], uncontrolled
|
|
25040
|
Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
|
|
25041
|
Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled
|
|
25042
|
Diabetes with renal manifestations, type II or unspecified type, uncontrolled
|
|
25043
|
Diabetes with renal manifestations, type I [juvenile type], uncontrolled
|
|
25050
|
Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled
|
|
25051
|
Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled
|
|
25052
|
Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
|
|
25053
|
Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled
|
|
25060
|
Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled
|
|
25061
|
Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled
|
|
25062
|
Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
|
|
25063
|
Diabetes with neurological manifestations, type I [juvenile type], uncontrolled
|
|
25070
|
Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled
|
|
25071
|
Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled
|
|
25072
|
Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled
|
|
25073
|
Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled
|
|
25080
|
Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled
|
|
25081
|
Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled
|
|
25082
|
Diabetes with other specified manifestations, type II or unspecified type, uncontrolled
|
|
25083
|
Diabetes with other specified manifestations, type I [juvenile type], uncontrolled
|
|
25090
|
Diabetes with unspecified complication, type II or unspecified type, not stated as uncontrolled
|
|
25091
|
Diabetes with unspecified complication, type I [juvenile type], not stated as uncontrolled
|
|
25092
|
Diabetes with unspecified complication, type II or unspecified type, uncontrolled
|
|
25093
|
Diabetes with unspecified complication, type I [juvenile type], uncontrolled
|
|
7751
|
Neonatal diabetes mellitus
|
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