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.
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.) (See Applicable Tennessee State Mandate Requirements 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. (See Applicable Tennessee State Mandate Requirements below.)
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.) (See Applicable Tennessee State Mandate Requirements below.)
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
Insulin pumps, infusion devices, and medically necessary accessories
Podiatric appliances for prevention of complications associated with diabetes
Glucagon emergency kits
Oral hypoglycemic agents
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
Tennessee Code Annotated, Title 56, Chapter 7, Part 2605
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
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.
Providers that will be recognized to provide the outpatient self-management diabetic training, educational services, and the nutritional counseling include:
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
American Diabetes Association. (2018, January). Standards of medical care in diabetes - 2018. Retrieved January 31, 2018 from: www.Diabetes.org/diabetescare.
American Optometric Association. (2014). Evidence-based clinical practice guideline: eye care of the patient with diabetes mellitus. Retrieved March 31, 2016 from the National Guideline Clearinghouse (NGC: 47915).
Centers for Medicare & Medicaid Services. CMS.gov. (201, July) National Coverage Determination (NCD) for diabetes outpatient self-management training (40.1). Retrieved February 17, 2017 from https://www.cms.gov.
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 January 31, 2018 from https://web.lexisnexis.com.
ORIGINAL EFFECTIVE DATE: 7/1/1997
MOST RECENT REVIEW DATE: 3/8/2018
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.