Diabetic Equipment and Supplies

15.1​Enrollment

To enroll in the CSHCN Services Program, providers of diabetic equipment and supplies must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Out-of-state diabetic equipment and supplies providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border, and approved by the Department of State Health Services (DSHS).

​Important:CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid.

By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 26 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371.

CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC §371.1659 for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 26 TAC §351.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid.

​Refer to: Section 2.1, “Provider Enrollment” in Chapter 2, “Provider Enrollment and Responsibilities” for more detailed information about CSHCN Services Program provider enrollment procedures.

15.2​Benefits, Limitations, and Authorization Requirements

Diabetic equipment and supplies including glucose monitors, testing supplies, insulin and insulin syringes, and external insulin pumps and supplies may be reimbursed by the CSHCN Services Program.

15.2.1​Glucose Monitor and Supplies

Blood testing supplies may be reimbursed without prior authorization when submitted with one of the following diagnoses:

15.2.1.1​Non Diabetic Diagnosis Codes

Diagnoses not listed may be considered for prior authorization with supporting documentation of medical necessity.

15.2.1.2​Glucose Monitor

The purchase of a blood glucose monitor may be reimbursed once every three years using the following procedure codes:

Blood glucose monitors with integrated voice synthesizers (procedure code E2100) and blood glucose monitors with integrated lancing blood sample (procedure code E2101) may be considered for prior authorization with documentation of medical necessity.

Prior authorization is required for blood glucose monitors with special features (procedure codes E2100 and E2101). The following documentation supporting medical necessity of the special feature requested must be submitted with the prior authorization request:

•​Integrated voice synthesizer. Supporting documentation for procedure code E2100 must include an additional diagnosis such as significant visual impairment and must include a statement from the physician that indicates that the client is unable to use a regular monitor and that the additional diagnosis or condition is not correctable.

•​Integrated lancing/blood sample. Supporting documentation for procedure code E2101 must include a diagnosis of diabetes and significant manual dexterity impairment related, but not limited to, neuropathy, seizure activity, cerebral palsy, or Parkinson’s. The documentation must include a statement from the physician indicating that the client is unable to use a regular monitor and has a significant manual dexterity impairment that is not correctable.

Standard home glucose monitors (procedure code E0607) are not a benefit of the CSHCN Services Program.

15.2.1.3​Glucose Testing Supplies

The following procedure codes may be reimbursed for glucose testing supplies when billed with one of the diagnosis codes listed in the Section 15.2.1, “Glucose Monitor and Supplies” in this chapter:

15.2.1.3.1​Insulin-Dependent Clients

The following procedure codes for diabetic supplies do not require authorization up to the quantities listed when they are provided to an insulin-dependent client with a valid diagnosis. If the client is insulin-dependent, providers must submit claims with modifier U9 for these procedure codes:

15.2.1.3.2​Non-Insulin-Dependent Clients

The following procedure codes for diabetic supplies do not require authorization up to the quantities listed when provided to a non-insulin-dependent client with an approved diagnosis:

Blood testing supplies for diagnoses other than those listed in the Section 15.2.1, “Glucose Monitor and Supplies” in this chapter may be considered for prior authorization with documentation of medical necessity.

For items that do not require prior authorization, the provider must indicate on a completed, signed prescription how many times a day the client is required to test blood glucose or ketone levels when applicable (not all supplies are related to testing glucose or urine, e.g., batteries).

15.2.1.4​Glucose Tabs and Gel

Procedure code A9150 may be reimbursed for glucose tablets or gel with prior authorization. Documentation of medical necessity and one of the diagnosis codes listed in the Section 15.2.1, “Glucose Monitor and Supplies” in this chapter must be included with the prior authorization request. Procedure code A9150 may be prior authorized with a quantity of 1 every 6 months as determined with prior authorization.

15.2.1.5​Prior Authorization Requirements

Diabetic supplies and related testing equipment do not require prior authorization unless otherwise specified in the specific sections of this chapter. Prior authorization is required when documentation of medical necessity supports additional quantities that exceed specified limits.

To avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the requested equipment or supplies. The physician must maintain documentation of medical necessity in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request for the diabetic equipment or supplies.

15.2.2​Continuous Glucose Monitors (CGM)

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:

A therapeutic or non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to confirm testing results. A non-therapeutic or adjunctive CGM requires the user to verify their glucose levels or the trends displayed on a CGM with a BGM before making treatment decisions.

The CGM system includes the following:

•​A disposable sensor (attaches to the skin and inserts a tiny wire into the subcutaneous tissue to measure glucose levels)

•​A transmitter (attaches to the sensor and sends the data to a wireless receiver/monitor)

•​A receiver/monitor (records and stores the data and alerts the client when glucose levels are too high or too low)

Only CGM consisting of all three parts including the sensor, transmitter, and receiver/monitor are covered. Coverage requires a dedicated receiver/monitor. A CGM that uses a smart device (e.g., smart phone, tablet, watch, personal computer) as a receiver is not classified as durable medical equipment and therefore not covered by the CSHCN Services Program.

The non-adjunctive CGM system includes the device (procedure code E2103) and associated supplies (procedure code A4239).

The adjunctive CGM system includes a receiver/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 non-durable medical equipment are informational only.

Procedure codes E2102 and E2103 are limited to once per three rolling years, any provider.

Other home glucose monitors (procedure codes E2100 and E2101) will be denied when submitted within three calendar years of procedure codes E2102 or E2103.

The supply allowance (procedure code A4238 or A4239) used with a CGM system encompasses all items necessary for the use of the device. The DME provider is responsible for delivering all appropriate items and quantities to the client for continuous usage of the CGM.

SBGM is used as a supplement to CGM devices. Allowance for SBGM supplies billed in addition to an approved CGM system will be reduced to four boxes for test strips (procedure code A4253) and two boxes for lancets (procedure code A4259) during the same calendar year by any provider.

The provider is responsible for submitting appropriate claims using procedure codes E2103 and A4239 for therapeutic devices and supplies. Claims must be submitted with modifier KF for a class III device (designated by FDA) and associated supplies. No modifier is required for a class II device (designated by FDA).

Procedure code A4239 will be denied when submitted during the same calendar month by any provider as procedure codes A4250, A4256, A9275, E2100, or E2101.

15.2.2.1​Prior Authorization Requirements

Prior authorization is required for a CGM device (procedure codes E2102 and E2103) and its associated supplies (procedure codes A4238 and A4239) that exceed the limit of once per calendar month. All prior authorization requests must be submitted on the CSHCN Services Program Prior Authorization Request for Diabetic Equipment and Supplies Form.

CGM must be prescribed by the health-care provider who manages the client’s diabetes. The order must include the make and model of the requested CGM device. A long-term personal CGM system for clients with diabetes to use at home may be considered for prior authorization for clients who have a documented diagnosis of insulin dependent diabetes mellitus and with clinical documentation of the following criteria:

•​The client uses BGM and performs frequent testing (at least four times per day).

•​The client has an insulin treatment regimen that requires frequent adjustments based on self blood glucose monitoring (SBGM) or CGM testing results.

•​There is documentation that the client demonstrates compliance with his or her insulin regimen by monitoring his or her blood sugar with finger sticks.

•​If the client already owns a monitor, the client must also meet at least two of the following criteria for the initial order of the monitor and supplies:

•​Elevated glycosylated hemoglobin level (HbA1c) > 7.0 percent

•​History of dawn phenomenon with fasting blood sugars that frequently exceed 200 mg/dL

•​History of severe glycemic excursions with wide fluctuations in blood glucose

•​History of recurring hypoglycemia (less than 60 mg/dL) with or without hypoglycemic unawareness

•​History of diabetic ketoacidosis

The provider must submit the CSHCN Services Program Prior Authorization Request for Diabetic Equipment and Supplies Form indicating the following:

•​The client or caregiver possesses the following competencies:

•​The cognitive and physical abilities to use the CGM

•​An understanding of cause and effect

•​The ability to learn to use the device

•​The ability to hear and view CGM alerts and respond appropriately

•​The willingness to support the use of the CGM

•​The prescribing provider attests the following:

•​A training or education plan will be completed prior to initiation of CGM therapy.

•​The client or caregiver will be given face-to-face education and instruction.

•​The client or caregiver will be able to demonstrate proficiency in integrating CGM therapy with the current treatment regimen for glucose control.

Prior to prescribing a CGM device, the ordering provider should verify that the client meets the CGM manufacturers’ recommendations for:

•​Medical Conditions.

•​Appropriate age range.

•​Testing and calibration requirements.

The initial prior authorization will be valid for six months. If the client complies with the use of the CGM and treatment plan, the physician may write an order and submit an updated PA request for an additional six months. After the first year, an order for replacement sensors, transmitter, and receiver may be submitted for a 12-month period.

15.2.2.2​Associated Supplies

When a CGM device (procedure code E2102 or E2103) is approved, the related supplies (procedure code A4238 or A4239) are also covered once per calendar month. Prior authorization for the related supplies is required only when the extra supplies provided exceed the allowance of once per calendar month.

Prior authorization to approve the initial once per calendar month allowance for the related supplies (procedure code A4238 or A4239) is also required when the client already owns a CGM device and the provider is not requesting a new CGM device. Clinical documentation of the following must be submitted with the prior authorization request:

•​The client-owned device meets the CMS definition of a non-adjunctive CGM.

•​A physician’s statement verifying the client’s current condition meets the non-adjunctive CGM coverage criteria.

SBGM-related supplies (procedure codes A4233, A4234, A4235, A4236, A4253, and A4259) provided within the same calendar month as an approved CGM device (procedure code E2103) and related supplies (procedure code A4239) will require prior authorization and documentation of medical necessity. Providers must use modifier U9 for insulin-dependent clients.

15.2.2.3​Noncovered Services

The following services are not benefits of the CSHCN Services Program:

•​Diagnostic glucose devices

•​CGM without a dedicated receiver

•​Smart devices (smart phones, tablets, personal computers, etc.) used as CGM monitors

•​Non-medical items, even if the items may be used to serve a medical purpose

15.2.3​Insulin Pump

An external insulin pump may be considered for rental or purchase with prior authorization and documentation of medical necessity. The following procedure codes may be reimbursed with prior authorization for the external insulin pump:

External insulin pump supplies do not require prior authorization up to the maximum quantities allowed. The following procedure codes may be reimbursed for the external insulin pump supplies:

Procedure codes A4230 and A4231 cannot be billed during the same calendar month.

Providers must bill the pump (procedure code E0784) used in the CGM integrated system with modifier UD. Providers also must bill procedure codes E2102 or E2103 with modifier U4 for the integrated system.

Additional quantities may be considered with documentation of medical necessity and prior authorization.

A tubeless external insulin pump (Omnipod) 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.

An external insulin pump must be ordered by, and the client’s follow-up care must be managed by, a prescribing provider with experience managing clients with insulin pumps and who is knowledgeable in the use of insulin pumps.

15.2.3.1​Prior Authorization Requirements

Prior authorization requests for the rental and purchase of the external insulin pumps (procedure code E0784) must be submitted on the CSHCN Services Program Prior Authorization Request for Diabetic Equipment and Supplies form. Supporting medical necessity documentation must include past and current blood glucose levels and the most recent glycosylated hemoglobin level (HbA1c).

The rental of an external insulin pump may be considered for prior authorization with submission of clinical documentation that indicates one of the following:

•​The client has a diagnosis of diabetes mellitus and meets at least 2 of the following criteria while on multiple daily injections of insulin:

•​Elevated glycosylated hemoglobin level (HbA1c) greater than 7.0 percent

•​History of dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL

•​History of severe glycemic excursions with wide fluctuations in blood glucose

•​History of recurring hypoglycemia (less than 60 mg/dL) with or without hypoglycemic unawareness

In addition to the clinical documentation, the provider must submit the CSHCN Services Program Prior Authorization Diabetic Equipment and Supplies form and include documentation that the client or caregiver possess the following competencies:

•​The cognitive and physical abilities to use the recommended insulin pump treatment regimen

•​An understanding of cause and effect

•​The willingness to support the use of the external insulin pump

The prior authorization request form must also include documentation that the prescribing provider has attested to the following:

•​A training/education plan will be completed prior to initiation of pump therapy.

•​The client or caregiver will be given face-to-face education and instruction and will be able to demonstrate proficiency in integrating insulin pump therapy with their current treatment regimen for ambient glucose control.

​Note:Providers may bill with procedure code A9900 for the replacement of alkaline batteries for the external ambulatory infusion pump during the rental period.

The purchase of an external insulin pump may be considered for prior authorization after it has been rented for a three-month trial period and all of the following documentation is provided:

•​The training/education plan has been completed.

•​The pump is the appropriate equipment for the specific client.

•​The client is compliant with the use of the pump.

Rental of an external insulin pump may be reimbursed for a 3-month trial, which must occur before purchase can be authorized.

In order for the external insulin pump to be considered for purchase, the physician must provide documentation that it is the appropriate equipment for the client and the client is compliant with use.

Replacement leg bag (procedure code A9900) must be prior authorized with documentation supporting medical necessity.

An internal insulin pump will not be prior authorized because the pump is included in the reimbursement for the surgery to place the pump.

15.2.3.2​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 thresholds of measured glucose levels and tells the pump to deliver or suspend the insulin into the client’s body.

Clients currently utilizing an external insulin pump or who 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 for an integrated system should be requested utilizing pump procedure code E0784 with modifier UD combined with one of the following CGM procedure codes:

•​E2102

•​E2103 with modifier U4

Tubeless external insulin pump (Omnipod) may be considered as an alternative to the CGM integrated pump system through prior authorization using pump procedure code E0784 with modifier U1 combined with disposable supply procedure code A9274.

Some CGM integrated pump systems might use smart devices to monitor the system instead of a CGM receiver/monitor. CSHCN Services Program excludes coverage for non-medical items, even when the items may be used to serve a medical purpose. The device provider is responsible for supplying the software applications to make the system work appropriately.

Once the client is on a CGM integrated insulin pump, either with therapeutic CGM capability or with adjunctive CGM capability, the claims for a stand-alone CGM will be denied.

The following modifiers should be used to bill for CGM integrated external insulin pump systems:

15.2.4​Insulin and Insulin Syringes

Insulin and insulin syringes are available through the Texas Medicaid Vendor Drug Program.

​Refer to: Section 3.1.1, “Prescription Drug Benefits” in Chapter 3, “Client Benefits and Eligibility” for more information.

15.3​Documentation of Receipt

When the equipment is delivered, providers must complete the CSHCN Services Program Documentation of Receipt form. The date of delivery on the form is the date of service that should appear on the claim. The provider must request a signature from the client or client’s representative at the time of delivery. The provider should retain this form and not submit it with the claim.

Providers must maintain a copy of this form in their files for the life of the piece of equipment or until the equipment is authorized for replacement.

The documentation of receipt form is available in both English and Spanish.

15.4​Claims Information

Diabetic equipment and supplies must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills or itemized statements are not accepted as claim supplements.

Home health DME providers must use benefit code DM3 on all claims and authorization requests. All other providers must use benefit code CSN on all claims and authorization requests.

The Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes included in policy are subject to National Correct Coding Initiative (NCCI) relationships. Exceptions to NCCI code relationships that may be noted in CSHCN Services Program medical policy are no longer valid. Providers should refer to the Centers for Medicare & Medicaid Services (CMS) NCCI web page for correct coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy quantity limitations are more restrictive than NCCI Medically Unlikely Edits (MUE) guidance, medical policy prevails.

​Refer to: Chapter 41, “TMHP Electronic Data Interchange (EDI)” for information on electronic claims submissions.

Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for general information about claims filing.

Section 5.7.2.4, “CMS-1500 Paper Claim Form Instructions” in Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.

15.5​Reimbursement

Diabetic equipment and supplies are reimbursed the lower of the billed amount, the amount allowed by CMS when available, or the amount allowed by Texas Medicaid.

For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com.

The CSHCN Services Program implemented rate reductions for certain services. The OFL includes a column titled “Adjusted Fee” to display the individual fees with all percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/resources/rate-and-code-updates/rate-changes.

​Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

15.6​TMHP-CSHCN Services Program Contact Center

The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community.