Effective for dates of service on or after August 1, 2023, diabetic equipment and supplies benefits will change for the Children with Special Health Care Needs (CSHCN) Services Program.
Continuous Glucose Monitors (CGMs)
A long-term personal CGM for clients to use at home may be considered with prior authorization with a documented diagnosis of insulin-dependent diabetes mellitus.
A therapeutic or nonadjunctive CGM can be used to make treatment decisions without the need for a stand-alone blood glucose monitor (BGM) to confirm testing results. A nontherapeutic or adjunctive CGM requires the user to verify their glucose levels or trends displayed on the CGM with a BGM prior to making treatment decisions.
The CGM system includes the following:
- 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 data to a wireless receiver or monitor
- A receiver or monitor, which records and stores data and alerts the client when glucose levels are too high or too low
The nonadjunctive CGM system includes the device (procedure code E2103) and associated supplies (procedure code A4239).
The adjunctive CGM system consists of a receiver or monitor (procedure code E2102) and associated supplies (procedure code A4238).
A CGM device (procedure code A9278) and associated supplies (procedure codes A9276 and A9277) for use with nondurable medical equipment (DME) are informational only.
CGM devices require prior authorization with documentation of medical necessity submitted with the CSHCN Services Program Prior Authorization Request for Diabetic Equipment and Supplies Form.
When a CGM device (procedure code E2102 or E2103) is covered, the related supply allowance (procedure code A4238 or A4239) is also covered with no need for prior authorization. Prior authorization is required for any additional quantity of supplies that exceeds the one per month supply allowance.
Prior authorization is also required for the initial nonadjunctive CGM allowance (procedure code A4238 or A4239) when ordered without the CGM device for a client who already owns the CGM device.
The supply allowance (procedure code A4238 or A4239) for use with a CGM system encompasses all necessary items for the use of the device.
Refer to: The current CSHCN Services Program Provider Manual, “Chapter 15: Diabetic Equipment and Supplies,” subsection 15.2.2.1, “Prior Authorization Requirements,” for prior authorization criteria that will also apply to a CGM system.
Omnipod
A tubeless external pump (Omnipod) is a benefit for clients of all ages. It may be considered for prior authorization and must be submitted using procedure code E0784 with modifier U1 and supply procedure code A9274 for the disposable pods, supplies, and accessories.
CGM Integrated External Insulin Pump
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 the thresholds of measured glucose levels, and it tells the pump to deliver or suspend the insulin into the client’s body.
Clients who are currently using an external insulin pump or meet the criteria for an external insulin pump may be reimbursed for a CGM specific pump and CGM device to form an integrated system through prior authorization.
Prior authorization is required for a CGM integrated pump system, which must be submitted using procedure code E0784 with modifier UD combined with either CGM procedure code E2102 or E2103 with modifier U4.
An Omnipod may be considered as an alternative to the CGM integrated pump system with prior authorization using CGM procedure code E0784 with modifier U1 combined with disposable supply procedure code A9274.
Some CGM integrated pump systems use smart devices to monitor the system instead of a CGM receiver or monitor. The device provider is responsible for supplying the software applications to make the system work appropriately.
Once the client uses a CGM integrated insulin pump, either with therapeutic CGM capability or adjunctive CGM capability, claims for stand-alone CGM devices will be denied.
The modifiers for a pump system are defined as follows:
|
Modifiers |
Description |
|
UD |
Used for pump with CGM for integrated pump system |
|
U1 |
Used for pump with Omnipod system |
|
U4 |
Used for CGM devices with pump for integrated pump system |
Reimbursement
The following procedure codes and related supplies are benefits in the home setting when the services are provided by home health durable medical equipment (DME), medical supplier DME, and custom DME providers:
|
Procedure Code |
Limitation |
|
A4238 |
1 per month |
|
A4239 |
1 per month |
|
E2102 |
1 per 3 years |
|
E2103 |
1 per 3 years |
The provider is responsible for submitting appropriate claims using procedure codes E2103 and A4239 for therapeutic devices and supplies. Claims must be submitted using the KF modifier for a class III device (designated by the Food and Drug Administration [FDA]) and associated supplies. A modifier is not required for a class II device (designated by the FDA).
The modifier for a class III CGM device is defined as follows:
|
Modifier |
Description |
|
KF |
Item designated by FDA as a class III device |
The limitations for the following procedure codes will be updated:
|
Procedure Code |
Limitation |
|
A4230 |
15 per month |
|
A6258 |
30 per month |
|
A6259 |
15 per month |
|
A9274 |
15 per month |
|
A9900 |
As needed with prior authorization |
|
E0784 – Purchase |
1 per 3 years as determined with prior authorization |
|
E0784 – Rental |
1 month as determined with prior authorization |
|
E2100 |
1 per 3 years as determined with prior authorization |
|
E2101 |
1 per 3 years as determined with prior authorization |
Procedure codes A4230 and A4231 may not be billed within the same calendar month.
For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.