Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.
Effective for dates of service on or after January 1, 2023, benefits pertaining to continuous glucose monitor and integrated insulin pump equipment and supplies will change under Texas Medicaid.
Overview of Benefit Changes
Major changes to this medical benefit include the following:
- New procedure codes for adjunctive continuous glucose monitors (CGMs)
- New procedure codes for CGM-integrated external insulin pumps with adjunctive CGM capability
- New benefit for CGM-integrated external insulin pumps with therapeutic CGM capability
Continuous Glucose Monitors
A therapeutic (nonadjunctive) CGM can be used to make treatment decisions without the need for a standalone blood glucose monitor (BGM) to confirm testing results. An adjunctive (nontherapeutic) CGM requires the user to verify their glucose levels or trends displayed on a CGM with a BGM prior to making treatment decisions.
A client with type 1 or 2 diabetes must meet all of the following medical necessity criteria for prior authorization:
- The client must be insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion pump.
- The client’s insulin treatment regimen must require frequent adjustments by the client based on BGM or CGM testing results.
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 additional prior authorization requirements.
Adjunctive CGM
Adjunctive CGM procedure codes A9276, A9277, and A9278 will become informational only, and they will be replaced by the following procedure codes:
- Procedure code E2102 for the device
- Procedure code A4238 for the supplies
Procedure code E2102 must be submitted with modifier KF when submitting a claim for a class III CGM device, as designated by the U.S. Food and Drug Administration (FDA). No modifier is required when submitting a claim for a class II device, as designated by the FDA.
The supply allowance for an adjunctive CGM (procedure code A4238) encompasses all items necessary for the use of the device and includes but is not limited to CGM sensors and transmitters. Procedure code A4238 does not include a home BGM or related BGM testing supplies.
No devices on the United States market function as standalone adjunctive CGM devices, according to the Centers for Medicare & Medicaid Services (CMS). Current technology for an adjunctive CGM device operates in conjunction with an insulin pump, and its supplies are covered when the client meets the coverage criteria for both a CGM and an external insulin infusion pump.
CGM Supplies
Prior authorization is not required for CGM supplies after a device is approved. When a CGM (procedure code E2102 or E2103) is covered, the related supply allowance (procedure code A4238 or A4239) is also covered.
The supply allowance (procedure code A4238 or A4239) will be one per 30 days. Only one procedure code A4238 or A4239 may be submitted at a time. Services that exceed this limitation will be denied as not reasonable and not necessary.
Requests for supplies for client-owned CGM devices require the ordering provider to submit a statement attesting that the client meets one of the following conditions:
- The client owns a CGM device, and the client’s current condition meets coverage criteria for a CGM.
- The client owns a CGM device and is compliant with using the CGM device to manage their diabetes.
CGM Integrated External Insulin Pumps
A CGM integrated pump (an insulin pump that has CGM capability) may be considered for prior authorization when the client meets the coverage criteria for both a CGM and an external insulin pump.
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 external insulin pump prior authorization requirements.
No prior authorization is required for CGM-integrated insulin pump supplies. When a CGM-integrated pump is covered, its supplies (procedure code A4238 or A4239) are also covered.
Adjunctive CGM-Integrated External Insulin Pump
Because procedure codes A9276, A9277, and A9278 will become informational, an insulin pump that has adjunctive CGM capability must be submitted using a combination of procedure code E0784 with modifier UD and new adjunctive CGM device procedure code E2102 with modifier U4.
Therapeutic CGM-Integrated External Insulin Pump
Insulin pumps that have therapeutic CGM capability will become a new benefit and must be submitted using a combination of procedure code E0784 with modifier UD and therapeutic CGM device procedure code E2103 with modifier U4.
Limitations
Only one CGM-integrated pump may be authorized for a qualified client who has a diabetes diagnosis. The ordering provider is responsible for requesting the appropriate device and supplies according to the client’s medical need using the appropriate procedure codes.
After the client has had a CGM-integrated insulin pump covered by Texas Medicaid, either with therapeutic CGM capability or adjunctive CGM capability, claims for a standalone CGM or regular external insulin pump will be denied.
For more information, call the TMHP Contact Center at 800-925-9126.