Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after September 1, 2021, diabetic equipment and supplies benefits will change for Texas Medicaid.
Overview of Benefit Changes
Major changes to this medical benefit include the following:
- Adding new benefit for adjunct continuous glucose monitoring (CGM) system
- Adding new benefit for CGM integrated insulin pump system
- Expanding the Omnipod benefit to adult diabetic population
Adjunct CGM System
CGMs are devices that measure glucose levels taken from interstitial fluid continually throughout the day and night, providing real-time data to the client or physician. The CGM has three parts:
- A disposable sensor, which attaches to the skin and inserts a tiny wire into the subcutaneous tissue to measure glucose levels
- A transmitter, which attaches to the sensor and sends the data to a wireless receiver/monitor
- A receiver/monitor, which records and stores the data and alerts the client when glucose levels are too high or too low
Disposable sensor procedure code A9276, external transmitter procedure code A9277, and receiver/monitor procedure code A9278 will be benefits when provided by medical supplier durable medical equipment (DME) providers in the home setting.
Procedure codes A9276, A9277, and A9278 will require prior authorization and will be limited as follows:
| Procedure Code | Limitation |
|---|---|
| A9276 | Up to 5 per month |
| A9277 | 1 per 3 months |
| A9278 | 1 per 3 years |
Prior authorization is required for a long-term personal CGM system for clients with diabetes to use at home. The CGM system may be one of the following:
- Therapeutic CGM system (as defined by the Centers for Medicare & Medicaid Services), which includes the supplies (procedure code K0553) and device (procedure code K0554), and replaces the use of a standard home blood glucose monitor (SBGM)
- Adjunct CGM system, which includes the sensor (procedure code A9276), transmitter (procedure code A9277), and receiver/monitor (procedure code A9278), and supplements the use of an SBGM
Refer to: The current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.12.5.1, “Prior Authorization,” for prior authorization criteria that will apply to therapeutic and adjunct CGM systems.
Only one type of CGM system, either therapeutic or adjunct, may be approved for qualified diabetic clients.
The ordering provider is responsible for requesting the appropriate device and supplies according to the client’s medical need and verifying that the client's condition meets the manufacturers' recommendations for appropriate age range, testing and calibration requirements, etc., prior to prescribing the CGM device.
If an adjunct CGM system is approved, the allowance for SBGM supplies submitted in addition to the approved adjunct CGM system will be reduced to two boxes of test strips (procedure code A4253) and one box of lancets (procedure code A4259) during the same calendar year by any provider.
CGM Integrated Insulin Pump System
A CGM integrated pump system, also called a closed-loop glucose management system, connects a CGM and an insulin pump. The system uses an algorithm to calculate insulin doses from the CGM readings based on thresholds of measured glucose levels and tells the pump to deliver or suspend the insulin into the client’s body.
Prior authorization is required for a CGM integrated pump system, which must be submitted using procedure code E0784 with modifier UD, and any of the three adjunct CGM system procedure codes (A9276, A9277, or A9278) with modifier U4.
Note: Some CGM integrated pump systems do not need a receiver/monitor (procedure code A9278) to carry out their function.
Refer to: The current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.12.6.1, “Prior Authorization,” for prior authorization criteria that will also apply to a CGM integrated pump system.
Some CGM integrated pump systems use smart devices to monitor the system instead of a CGM receiver/monitor. The device provider is responsible for supplying the software applications to make the system work appropriately.
Omnipod
A tubeless external insulin pump (Omnipod) will be a benefit for clients of all ages as an alternative to the CGM integrated pump system.
Prior authorization is required for Omnipod, which must be submitted using procedure code E0784 with modifier U1 and supply procedure code A9274 for the disposable pods, supplies, and accessories.
Refer to: The current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.12.6.1, “Prior Authorization,” for prior authorization criteria that will also apply to an Omnipod.
For more information, call the TMHP Contact Center at 800-925-9126.