Diabetes Management
DESCRIPTION
Diabetes is a chronic illness that requires continuing medical care and education in order to prevent acute complications and reduce the risk of developing other conditions related to uncontrolled blood glucose. These other conditions may include retinopathy, nephropathy, neuropathy and cardiovascular disease.
POLICY
Diabetes outpatient treatment, self-management training, education, and nutrition counseling, when ordered by a physician for the treatment of diabetes is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Glycosylated Hemoglobin A1c (HbA1c) testing at intervals of once every 3-6 months, when ordered by a physician, for individuals with Type I or Type II diabetes is considered medically necessary.
Diagnostic services, supplies, durable medical equipment, and medications, when prescribed by a physician for the treatment of diabetes, are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
Diabetes management is considered medically appropriate if ANY ONE of the following are met:
Diabetes outpatient treatment, self-management training, education, and nutrition counseling, when ordered by a physician for the treatment of diabetes, if ANY ONE of the following are met:
Upon the diagnosis of diabetes
There is a significant change in the individual's symptoms or condition which necessitates changes in the individual's self-management
Re-education or refresher training
Diagnostic services, supplies, durable medical equipment, and medications, when prescribed by a physician for the treatment of diabetes, for ANY ONE of the following:
Blood glucose monitors - including monitors for the legally blind
Test strips for blood glucose monitors
Visual reading and urine test strips
Injection aids
Syringes
Lancets
Insulin pumps, infusion devices, and medically necessary accessories
Podiatric appliances for prevention of complications associated with diabetes
Glucagon emergency kits
Insulin
Oral hypoglycemic agents
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Providers that will be recognized to provide the outpatient self-management diabetic training, educational services, and the nutritional counseling include:
Licensed physicians
Registered nurses or dietitians
Pharmacists who have completed a diabetic patient management program recognized by the American Council on Pharmaceutical Education and the Tennessee Board of Pharmacy
Other contracted or credentialed providers may be recognized as eligible providers following evaluation and approval by BlueCross BlueShield of Tennessee
Providers will be required to be credentialed and contracted with BlueCross BlueShield of Tennessee.
Accepted in accordance with the 1997 State mandate.
SOURCES
111th Congress: 1st Session: HR. 2425: (2009, May). Medicare Diabetes self-management training act of 2009. Retrieved July 15, 2010 from http://thomas.loc.gov .
Agency for Healthcare Research and Quality. (2008 October) A proposed framework to evaluate home tests for use in the management of chronic disease. Retrieved July 15, 2010 from http://www.cms.gov/determinationprocess/downloads/id62TA.pdf.
American Association of Clinical Endocrinologists. (2007 May). American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Retrieved July 15, 2010 from http://www.aace.com/pub/pdf/guidelines/DMGuidelines2007.pdf.
American Diabetes Association. (2010). Third-party reimbursement for diabetes care, self-management education, and supplies. Diabetes Care, 33 (Suppl. 1), S87-S88.
Anselmo, M., Nery, M., & Parisi, M. (2010). The effectiveness of educational practice in diabetic foot: a view from Brazil. Diabetology and Metabolic Syndrome, 2 (1), 45. (Level 5 Evidence)
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Blood glucose monitors (Glucometers) (1.01.03). Retrieved July 14, 2010 from BlueWeb. (1 article and/or guidelines reviewed)
Center for Disease Control and Prevention. (2007). Take charge of your diabetes. Retrieved July 15, 2010 from http://www.cdc.gov/diabetes/pubs/pdf/tcyd.pdf
Center for Disease Control and Prevention. (2010). Diabetes successes and opportunities for population-based prevention and control. Retrieved July 15, 2010 from http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2010/diabetes_aag.pdf.
Complete Guide to Medicare Coverage Issues [Computer software]. (2010, April). Infusion pumps (NCD 280.14, p. 2-217, 2-218, 2-219). The Ingenix Complete Guide to Medicare Coverage Issues.
Complete Guide to Medicare Coverage Issues [Computer software]. (2010, April). Therapeutic shoes for individuals with diabetes (section 140, 4-230, 4-231). The Ingenix Complete Guide to Medicare Coverage Issues.
Complete Guide to Medicare Coverage Issues [Computer software]. (2010, April). Diabetes outpatient self-management training (NCD 40.1, p. 2-32, 2-33). The Ingenix Complete Guide to Medicare Coverage Issues.
Complete Guide to Medicare Coverage Issues [Computer software]. (2010, April). Home blood glucose monitors (NCD 40.2, p. 2-33). The Ingenix Complete Guide to Medicare Coverage Issues.
Complete Guide to Medicare Coverage Issues [Computer software]. (2010, April). Closed loop blood glucose control device (NCD 40.3, p. 2-34). The Ingenix Complete Guide to Medicare Coverage Issues.
Complete Guide to Medicare Coverage Issues [Computer software]. (2010, April). Insulin syringe (NCD 40.4, p. 2-34). The Ingenix Complete Guide to Medicare Coverage Issues.
Edelman, D., Fredrickson, S., Melnyk, S., Coffman, C., Jeffreys. A., Datta, S., et al. (2010). Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial. Annals of Internal Medicine, 152 (11), 689 - 696. (Level 1 Evidence)
National Guideline Clearinghouse. Michigan Quality Improvement Consortium. (2008 June). Management of diabetes mellitus. Southfield (MI): Michigan Quality Improvement Consortium. Retrieved November 21, 2008 from http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=13173&string=management+AND+diabetes+AND+Mellitus.
Schnell, O., Hummel, M., & Weber, C. (2008). Economic and clinical aspects of diabetes regarding self-monitoring of blood glucose. Diabetes Technology and Therapeutics, 10 (s1), S-72 - S-81. (Level 5 Evidence)
Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 26 Mandated Insurer or Plan Options: 56-7-2605. Equipment, supplies and outpatient services for diabetic patients. Retrieved November 6, 2007 from http://www.michie.com/tennessee/lpext.dll?f=templates&fn=main-h.htm&cp=tncode.
U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. Overview. (May, 2010). Diabetes self-management, supplies, and other medical services introduction. Retrieved July 15, 2010 from http://www.cms.gov/DiabetesSelfManagement/.
U. S. Food and Drug Administration. (2008, January). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K071788. Retrieved July 15, 2010 from http://www.accessdata.fda.gov/cdrh_docs/pdf7/K071788.pdf.
U. S. Food and Drug Administration. (2010, April). Center for Devices and Radiological Health. Infusion pump improvement initiative. Retrieved July 15, 2010 from http://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/UCM206189.pdf.
ORIGINAL EFFECTIVE DATE: 7/1/1997
MOST RECENT REVIEW DATE: 9/9/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.