HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
E-15-045
Topic:
Diabetic Services, Continuous Glucose Monitoring, and Supplies
Section:
Durable Medical Equipment
Effective Date:
April 1, 2024
Issued Date:
April 1, 2024
Last Revision Date:
March 2024
Annual Review:
November 2023
 
 

Diabetes outpatient self-management and training service is a program which educates individuals in self-monitoring of blood glucose, diet, exercise, and insulin management.

Continuous Glucose Monitoring (CGM) Systems (also known as Real-Time or interstitial) monitor, measure, and record glucose levels in interstitial fluid and produce data that show trends in glucose measurements. CGM systems consist of a sensor, transmitter and receiver. Currently, CGM system sensors can be used 3-90 days before replacement. Personal CGM system can exist as a stand-alone system or integrated with an insulin pump. Glucose results are used by the individual to closely monitor their glucose levels to help them to better self-manage their diabetes.

Orthotics protect, restore and/or improve the function of moveable parts of the body with orthopedic appliances or apparatus. Orthotic appliances or apparatus support, align, prevent and/or correct deformities. 

Policy Position

Pennsylvania Mandate

Effective February 12, 1999 as defined by Pennsylvania Act 98 - 1998 Diabetes Supplies and Education Mandate diabetic services and education orthotics equipment and supplies are eligible for patients with insulin or noninsulin dependent diabetes insulin or noninsulin using diabetes or gestational diabetes. These services and supplies must be prescribed by a health care professional legally authorized to prescribe such items. Therefore requests for these services and supplies must include a physician prescription including necessary information for the service or supply being requested,

Coverage for the services as defined by Pennsylvania Act 98 - 1998 for diabetic services and supplies are subject to annual deductibles and coinsurances and all other terms and conditions set forth in the patient's contract.


Diabetic Equipment and Supplies

The following diabetic equipment and supplies designed for individual use are eligible for coverage when prescribed by a physician:

  • Insulin; or
  • Injection aids; or
  • Injection aids, including insulin; or
  • Syringes and needles; or
  • Insulin infusion devices and related supplies; or
  • Pharmacological agents for controlling blood sugar; or
  • Blood glucose monitors; or
  • Monitor supplies; or
  • Skin prep supplies; or
  • Supplies.  

Diabetic equipment and supplies are covered when the glucose monitor is covered.

A4206

A4207

A4208

A4209

A4210

A4211

A4213

A4215

A4222

A4224

A4225

A4230

A4231

A4232

A4233

A4234

A4235

A4236

A4244

A4245

A4246

A4247

A4250

A4252

A4253

A4255

A4256

A4257

A4258

A4259

A9274

A9275

E0607

E0620

E0784

E0787

E1399

E2100

E2101

E2104

J1610

J1815

J1817

K0552

K0601

K0602

K0603

K0604

K0605

S1034

S1035

S1036

S1037

S5000

S5001

S5550

S5551

S5552

S5553

S5560

S5561

S5565

S5566

S5570

S5571

S8490

 

 

 

 

 

 

 

 

 

 

 




External Insulin Infusion Pumps for Adults

A United States Food and Drug Administration (U.S. FDA) approved external insulin pump for the management of diabetes mellitus may be considered medically necessary for individuals that meet ALL of the following criteria:

  • Has completed a comprehensive diabetes education program; and
  • The individual has been on a program of multiple daily injections (i.e., at least three (3) injections per day), with frequent self-adjustments of insulin dose for at least six (6) months to initiation of the insulin pump; and
  • The individual has documented frequency of glucose self-testing an average of at least four (4) times per day during the two months prior to initiation of the insulin pump or utilizing a continuous glucose monitor; and
  • The individual meets at least one of the following criteria while on multiple daily injections (more than three (3) injections per day) of insulin:
    • Glycosylated hemoglobin level (HbAlc) greater than 7.0%; or
    • History of recurring hypoglycemia; or
    • Wide fluctuations in blood glucose before mealtime; or
    • Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or
    • History of severe glycemic excursions; or
    • The individual has been on a pump prior to enrollment in the health plan, and has documented frequency of glucose self-testing an average of at least four (4) times per day during the month prior to health plan enrollment.

Continued coverage of an external insulin pump and supplies, when the insulin pump has been   approved initially, includes the following:

  • The individual must be evaluated by the treating provider at least every six (6) months; and
  • Follow-up care must be rendered by a provider who manages multiple individuals on continuous subcutaneous insulin infusion therapy, and who works closely with a diabetes care team including nurses, diabetic educators, and dieticians who are knowledgeable and trained in the use of continuous subcutaneous insulin infusion.

Replacement insulin pump may be considered medically necessary for the following indications:

  • Insulin infusion pumps that are out of warranty, are malfunctioning and cannot be repaired; or
  • Replacement of an external insulin pump may be medically necessary for individuals who require the closed loop insulin pump system if the individual meets the criteria as indicated in this policy.

Replacement insulin pump would be considered not medically necessary for a functioning insulin pump with an insulin pump with wireless communication to a glucose monitor.

Individuals not meeting the as indicated in this policy criteria for external insulin pumps is considered not medically necessary

A4224

A4225

A4230

A4231

A4232

A9274

E0784

E0787

 

 

 

 

 

 




An U.S. FDA approved continuous glucose monitor and sensor augmented insulin pump and a Hybrid closed loop system with continuous glucose monitor (CGM) may be considered medically necessary for individuals that meet ALL the following indications:

  • Follow U.S. FDA age requirements for the device: and
  • Individual or caregiver must have completed a comprehensive diabetes program; and
  • The individual’s treatment regimen requires frequent insulin adjustment by the individual based on blood glucose meter testing results or while utilizing a continuous glucose monitor; and
  • The individual meets at least one of the following criteria while on multiple daily injections program of multiple daily injections (i.e., at least three (3) injections per day), with frequent self-adjustments of insulin dose:
    • History of frequent hypoglycemia; or
    • Hypoglycemia unawareness; or
    • Inability to hear the alerts of the CGM at night; or
    • Severe hypoglycemic episodes.

 

Use of a continuous glucose monitor and sensor augmented insulin pump and a closed loop system including the Hybrid for not meeting the criteria as indicated in this policy is considered experimental/investigational because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

S1034

S1035

S1036

S1037

 

 

 




External Insulin Infusion Pumps for Children 18 and Under Including Neonates

An U.S. FDA approved external insulin pump for children 18 and under the management of diabetes mellitus may be considered medically necessary for individuals that meet ALL of the following criteria:

  • Has completed a comprehensive diabetes education program; and
  • The individual has been on a program of multiple daily injections (i.e., at least three (3) injections per day), with frequent self-adjustments of insulin dose for at least six (6) months to initiation of the insulin pump; and
  • The individual has documented frequency of glucose self-testing an average of at least four (4) times per day during the two months prior to initiation of the insulin pump or utilizing a continuous glucose monitor; and
  • The individual meets at least one of the following criteria while on multiple daily injections (more than three (3) injections per day) of insulin:
    • Glycosylated hemoglobin level (HbAlc) greater than 7.0%; or
    • History of recurring hypoglycemia; or
    • Wide fluctuations in blood glucose before mealtime; or
    • Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or
    • History of severe glycemic excursions; or
    • The individual has been on a pump prior to enrollment in the health plan, and has documented frequency of glucose self-testing an average of at least four (4) times per day during the month prior to health plan enrollment.

Continued coverage for children 18 and younger of an external insulin pump and supplies, when the insulin pump has been approved initially, includes the following:

  • The individual must be evaluated by the treating provider at least every six (6) months; and
  • Follow-up care must be rendered by a provider who manages multiple individuals on continuous subcutaneous insulin infusion therapy, and who works closely with a diabetes care team including nurses, diabetic educators, and dieticians who are knowledgeable and trained in the use of continuous subcutaneous insulin infusion therapy.

Individuals not meeting the criteria as indicated in this policy for external insulin pumps is considered not medically necessary.

Replacement insulin pump is considered medically necessary for children 18 and younger for the following indications:

  • Insulin infusion pumps that are out of warranty, are malfunctioning and cannot be repaired; or
  • For children who require a larger insulin reservoir; or
  • For children who require the closed loop insulin pump system if the individual meets the above criteria.

A4224

A4225

A4230

A4231

A4232

A9274

E0784

E0787

 

 

 

 

 

 




Short Term Interstitial CGM

Use of an U.S. FDA approved short term interstitial CGM, minimum of 72 hours may be considered medically necessary for type I or type II diabetics when ANY ONE of the following criteria are met:

  • History of poorly controlled diabetes (i.e., unexplained hypoglycemic episodes, hypoglycemic unawareness, suspected postprandial hyperglycemia, and recurrent diabetic ketoacidosis); or
  • Pregnant female that requires insulin therapy; or
  • Pregnant female who develops gestational diabetes; or
  • An individual who requires determination of basal insulin level measurements prior to insulin pump initiation; or
  • An individual who has documentation of ALL of the following:
    • Inability to recognize or communicate their symptoms of hypoglycemia; and
    • Pediatric individuals (age 2 (two) to 18 years of age) must be managed by endocrinologist; and
    • The parent or caregiver must have the ability to understand the technology and be willing to use the monitor, read and interpret the glucose data; and
    • Received diabetes self-management education and instruction from a health care professional with expertise in the management of diabetes; and
    • Is on an intensive insulin regimen, requiring three (3) or more insulin administrations per day, or utilizes an insulin pump; and
    • Has ONE or MORE of the following while on an intensive insulin regimen:
      • Unexplained large fluctuations in daily glucose values before meals; or
      • Unexplained frequent hypoglycemic attacks (e.g., greater than one (1) per week or three (3) per month); or
      • Episodes of ketoacidosis or hospitalizations for significantly elevated glucose levels.

For short-term diagnostic use, no more than four (4) CGM periods may be considered medically necessary within a 12-month period. 

Short-term interstitial CGM not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

 

95249

95250

95251

 

 

 

 




Long Term Interstitial CGM Systems

Use of an U.S. FDA approved long term interstitial CGM system as an adjunct and non-adjunct (i.e., greater than 72 hours) may be considered medically necessary for type I or type II diabetics when ANY ONE of the following criteria are met:

  • Pregnant female with poorly controlled diabetes (i.e., unexplained hypoglycemic episodes, hypoglycemic unawareness, suspected postprandial hyperglycemia, and recurrent diabetic ketoacidosis); or  
  • Recurrent, unexplained, severe (generally blood glucose levels less than 50 mg/dL) hypoglycemia that puts the individual or others at risk; or
  • History of poorly controlled diabetes (i.e., unexplained hypoglycemic episodes, hypoglycemic unawareness, suspected postprandial hyperglycemia, and recurrent diabetic ketoacidosis); and
  • Documentation of ALL of the following:
    • The CGM is prescribed by a professional provider; and
    • Is on an intensive insulin regimen, requiring three (3) or more insulin administrations per day, or utilizes an insulin pump; and
    • The individual (parent or caregiver if individual is a child) has been instructed by a health care professional in the management of diabetes including care of the CGM, alarm use and problem solving and use of real time CGM application in diabetic care; and
    • Pediatric individuals (age 2 (two) -12 years old: The CGM is recommended and managed by a pediatric endocrinologist:
      • Note: CGM may be approved for those under two (2) years of age with exceptional circumstances requiring individual consideration; and
    • The individual (parent or caregiver if the individual is a child) must have the ability to understand the technology and be willing to use the monitor (I.e., hear alarms, read and interpret glucose data and can take action based on the data interpretation; and
    • The responsible individual demonstrates mastery of the fundamentals of diabetes self-management, which includes BOTH of the following:
      • Routine, regular testing of blood glucose levels; and
      • Maintaining accurate records of blood glucose testing.

Long-term interstitial CGM system not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Receiver/Reader kits are limited to one (1) per Benefit Period. Sensor kits are limited to one (1) unit every thirty (30) days, unless otherwise required due to manufacturer packaging restrictions. Transmitter kits are limited to (1) unit every ninety (90) days unless otherwise required due to manufacturer packaging restrictions.

95249

95250

95251

0446T

0447T

0448T

A4226

A4238

A4239

A4271

A9276

A9277

A9278

E2102

E2103

 

 

 

 

 

 




Non-invasive CGM

Non-invasive CGM and related supplies are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

S1030

S1031

 

 

 

 

 




Remote CGM

A remote interstitial CGM (e.g., mySentry™) is considered investigational/experimental and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

A9999

0740T

0741T

 

 

 

 




Supplies related to continuous subcutaneous insulin infusion via external insulin infusion pump and the infusion sets and dressings are limited to manufacturer recommendations.

Replacement supplies related to continuous subcutaneous insulin infusion via external insulin infusion pump and the infusion sets and dressings may be considered medically necessary and are limited to manufacturer recommendations.

Supplies exceeding the manufacturer’s recommendation will be denied as not medically necessary.

A4224

A4230

A4231

 

 

 

 




Quantity Level Limits (QLL) for test strips, lancets, and lens shield cartridge 

The quantity of test strips, lancets and replacement lens shield cartridges that are covered depends on the medical needs of the diabetic individual according to the following guidelines: 

Pediatric

Less than or equal to 12 years old and under:    

  • Test strips*- 300 per one (1) month and 900 every 90 days; and
  • Lancets**- 300 per one (1) month and 900 every 90 days; or
  • Lens shield cartridge- one (1) every one (1) month. 

Adolescent/Adult

Greater than or equal to 13 years old: 

  • Test strips*- 300 up to 30 days and 612 every 35-90 days; and
  • Lancets**- 300 up to 30 days and 612 every 35-90 days; or
  • Lens shield cartridge- one (1) every one (1) month.  

When ALL of the following criteria are met: 

  • The equipment and supplies are prescribed by a physician; and
  • The glucose monitor is covered; and
  • The supplier of the test strips and lancets or lens shield cartridge maintains in its records the order from the treating physician; and
  • The individual has nearly exhausted the supply of test strips and lancets or useful life of one lens shield cartridge previously dispensed. 

*Glucose test strips - one (1) unit of service = one (1) box (50-51 strips). 

**Lancets- one (1) unit of service = one (1) box (100 lancets). 

Quantity of supplies that exceeds the frequency guidelines listed on the policy are considered not medically necessary.

All Diabetic Individuals

  • Spring powered device-one (1) every six (6) months.

 

More than one (1) spring powered device every six (6) months is considered not medically necessary. 

A4253

A4257

A4258

A4259

 

 

 




QLLs Exceeded for test strips, lancets, or lens shield cartridge

QLLs that exceed the allowed amount of strips, lancet, and lens shield cartridges may be considered medically necessary when ALL of the following are met.

  • The equipment and supplies are prescribed by a physician; and
  • The glucose monitor is covered; and
  • The supplier of the test strips and lancets, or lens shield cartridge maintains in its records the order from the treating physician; and
  • The individual has nearly exhausted the supply of test strips and lancets, or useful life of one (1) lens shield cartridge previously dispensed; and
  • The treating physician has ordered a frequency of testing that exceeds the frequency guidelines in this policy and has documented in the individual's medical record the specific reason for the additional materials for that particular individual; and
  • The treating physician has seen the individual and has evaluated their diabetes control within six (6) months prior to ordering quantities of strips and lancets, or lens shield cartridges that exceed the frequency guidelines in this policy; and
  • If refills of quantities of supplies that exceed the frequency guidelines in this policy are dispensed, there must be documentation in the physician's records (e.g., a specific narrative statement that adequately documents the frequency at which the individual is actually testing or a copy of the member's log) or in the supplier's records (e.g., a copy of the member's log) that the individual is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the individual is regularly using quantities of supplies that exceed the frequency guidelines in this policy, new documentation must be present at least every six (6) months. 

QLLs of test strips, lancets, or lens shield cartridges not meeting the criteria as indicated in this policy and exceeding the frequency guidelines in this policy are considered not medically necessary.

A4253

A4257

A4259

 

 

 

 




I-Port Injection Port (Patton Medical Devices)

I-Port Injection Port (Patton Medical Devices) is considered experimental/investigational and, therefore, non-covered. There is a lack of scientific-based evidence of long-term studies demonstrating the safety and efficacy of this device.

E1399

           



V-Go Disposable Insulin Delivery Device

 V-Go disposable nonprogrammable insulin delivery device for the management of Type 1 or Type 2 diabetes mellitus is considered experimental/investigative and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. 

E1399

 

 

 

 

 

 




Diabetes Outpatient Self-Management and Training Services 

Diabetes outpatient self-management and training services may be considered medically necessary for the diabetic individual, in ANY of the following circumstances:

  • Initial diagnosis of diabetes; or   
  • Significant change in the individual’s symptoms or condition, such as fluctuation in blood glucose values, risk for hypoglycemic events; or
  • Uncontrolled diabetes despite optimization of medical therapy; or
  • The introduction of new medication or new therapeutic process in the treatment/management of the individual’s symptoms/condition.    

Self-management and training services not meeting the criteria as indicated in this policy are considered not medically necessary

G0108

G0109

S9140

S9141

S9145

S9455

S9460

98960

98961

98962

 

 

 

 




Orthotics 

Diabetic shoes and the Lang Medical Shoe foot pressure off-loading/supportive devices inserts and/or modifications to those shoes are eligible when BOTH of the following criteria are met:

  • The individual has diabetes mellitus; and
  • The individual has one (1) or more of the following conditions:
    • Previous amputation of the other foot or part of either foot; or  
    • History of previous foot ulceration of either foot; or
    • History of pre-ulcerative calluses of either foot; or
    • Peripheral neuropathy with evidence of callus formation of either foot; or
    • Foot deformity of either foot; or
    • Poor circulation in either foot.  

Orthotics not meeting the criteria as indicated in this policy are considered not medically necessary.


QLLs for Diabetic Shoes and Inserts

Individuals meeting the above orthotic coverage are limited to ONE (1) of the following within one (1) calendar year:

  • One (1) pair of custom-molded shoes and two (2) pairs of inserts; or
  • One (1) pair of depth shoes and three (3) pairs of inserts (not including the non-customized removable inserts provided with such shoes).

A modification of a custom-molded or depth shoe may be considered medically necessary as a substitute for an insert. Custom-molded and depth shoe modification payments may not exceed the limit set for inserts. The following list of common shoe modifications is not an exhaustive list:

  • Wedges; or
  • Roller bottoms; or
  • Offset heels; or
  • Metatarsal bars; or
  • Rigid rocker bottoms.

Diabetic shoes, modifications, and inserts not meeting the criteria as indicated in this policy are considered not medically necessary.

A5500

A5501

A5503

A5504

A5505

A5506

A5507

A5510

A5512

A5513

A5514

A9283

E1399

L2999




Deluxe Shoe Feature is non-covered because it does not contribute to the therapeutic function of the shoe. Features may include but are not limited to style color or type of leather.

A5508

 

 

 

 

 

 




Related Policies

See Medical Policy Z-27, Eligible Providers and Supervision Guidelines, for additional information.

See Medical Policy O-8, Braces and Supports, for additional information.

See Medical Policy O-24, Ankle-Foot/Knee-Ankle-Foot Orthosis, for additional information.


Covered Diagnosis Codes for Procedure CodesA4224, A4225, A4230, A4231, A4232, A9274, and E0784

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3521

E08.3522

E08.3523

E08.3529

E08.3531

E08.3532

E08.3533

E08.3539

E08.3541

E08.3542

E08.3543

E08.3549

E08.3551

E08.3552

E08.3553

E08.3559

E08.3591

E08.3592

E08.3593

E08.3599

E08.36

E08.37X1

E08.37X2

E08.37X3

E08.37X9

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E08.65

E08.69

E08.8

E08.9

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3521

E09.3522

E09.3523

E09.3529

E09.3531

E09.3532

E09.3533

E09.3539

E09.3541

E09.3542

E09.3543

E09.3549

E09.3551

E09.3552

E09.3553

E09.3559

E09.3591

E09.3592

E09.3593

E09.3599

E09.36

E09.37X1

E09.37X2

E09.37X3

E09.37X9

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E09.65

E09.69

E09.8

E09.9

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3539

E10.3541

E10.3542

E10.3543

E10.3549

E10.3551

E10.3552

E10.3553

E10.3559

E10.3591

E10.3592

E10.3593

E10.3599

E10.36

E10.37X1

E10.37X2

E10.37X3

E10.37X9

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.10

E11.11

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3521

E11.3522

E11.3523

E11.3529

E11.3531

E11.3532

E11.3533

E11.3539

E11.3541

E11.3542

E11.3543

E11.3549

E11.3551

E11.3552

E11.3553

E11.3559

E11.3591

E11.3592

E11.3593

E11.3599

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.37X9

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3521

E13.3522

E13.3523

E13.3529

E13.3531

E13.3532

E13.3533

E13.3539

E13.3541

E13.3542

E13.3543

E13.3549

E13.3551

E13.3552

E13.3553

E13.3559

E13.3591

E13.3592

E13.3593

E13.3599

E13.37X1

E13.37X2

E13.37X3

E13.37X9

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

E13.65

E13.69

E13.8

E13.9

O24.011

O24.012

O24.013

O24.019

O24.02

O24.03

O24.111

O24.112

O24.113

O24.119

O24.12

O24.13

O24.311

O24.312

O24.313

O24.319

O24.32

O24.33

O24.410

O24.414

O24.419

O24.420

O24.424

O24.429

O24.430

O24.434

O24.439

O24.811

O24.812

O24.813

O24.819

O24.82

O24.83

O24.911

O24.912

O24.913

O24.919

O24.92

O24.93

O99.810

O99.814

O99.815

P70.2

Z79.4

 

 

 

 

 

Covered Diagnosis codes for Procedure Codes: A4226, A4238, A4239, A4271,  A9276, A9277, A9278, E2102, E2103, E2104, 0446T, 0447T, 0448T, 95249, 95250, and 95251 (Short and Long Term Interstitial)

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3291

E10.3292

E10.3293

E10.3311

E10.3312

E10.3313

E10.3391

E10.3392

E10.3393

E10.3411

E10.3412

E10.3413

E10.3491

E10.3492

E10.3493

E10.3511

E10.3512

E10.3513

E10.3521

E10.3522

E10.3523

E10.3529

E10.3531

E10.3532

E10.3533

E10.3541

E10.3542

E10.3543

E10.3551

E10.3552

E10.3553

E10.3591

E10.3592

E10.3593

E10.36

E10.37X1

E10.37X2

E10.37X3

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.10

E11.11

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3291

E11.3292

E11.3293

E11.3311

E11.3312

E11.3313

E11.3391

E11.3392

E11.3393

E11.3411

E11.3412

E11.3413

E11.3491

E11.3492

E11.3493

E11.3511

E11.3512

E11.3513

E11.3521

E11.3522

E11.3523

E11.3531

E11.3532

E11.3533

E11.3541

E11.3542

E11.3543

E11.3551

E11.3552

E11.3553

E11.3591

E11.3592

E11.3593

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

O24.011

O24.012

O24.013

O24.019

O24.02

O24.03

O24.111

O24.112

O24.113

O24.119

O24.12

O24.13

O24.414

O24.419

O24.424

O24.429

O24.434

O24.439

Z79.4

 

 

 

 

 



Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Diabetic services, continuous glucose monitoring, and supplies are typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting. is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



Links






This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.