Chapter 14 Durable Medical Equipment (DME)

Durable Medical Equipment (DME) 14Home Blood Glucose Monitor (E0607)Home blood glucose monitors will be considered for Medicaid beneficiaries diagnosedas having either Type 1, Type 2, or Gestational Diabetes Mellitus. Home blood glucosemonitors must be prescribed as medically necessary by the primary physician and priorauthorized by EDS, and at least two of the following medical criteria must be met:• Home blood glucose monitoring is required two or more times a day.• Physician identifies or diagnoses a recurrence in the recipient’s symptoms(hyperglycemia, hypoglycemia) that may be prevented, delayed, or controlled byself-monitoring the blood sugar.• Recipient has had at least one emergency room visit or one hospital admissionrelated to diabetes complications within the 12 months prior to the date of therequest.• Recipient has uncontrolled diabetes manifested by two or more fasting bloodsugars of greater than 126 mg/dl, hemoglobin Alc > 7.0%, or random blood sugar >150 mg/dl.• Recipient experiences complications resulting from poor diabetes control includingneuropathy, nephropathy, retinopathy, recurrent hyperglycemia/hypoglycemia,repeated infections or non-healing wounds, stroke, and cardiovascular disease.• Recipient has experienced two or more HbAlc levels < 4.0 % or >7.0%, at leastthree months apart.The dispensing provider must submit documentation that justifies at least two of themedical criteria above to EDS for prior authorization within thirty calendar days fromthe date the equipment was dispensed. This alone does not guarantee approval.Medical necessity must be determined by Medicaid professional staff. A review of thesubmitted documentation will determine medical necessity. The request may beapproved or denied, or additional information may be requested. Documentation mustalso include the physicians’ certification that the recipient or their caregiver is receiving,or has received, diabetes education and training for the use the glucose monitor in theappropriately prescribed manner for use in the home.Requests for Medicaid’s authorization of a replacement glucose monitor will beaccepted for review every two years from the initial physician’s certification date.Medicaid will consider requests for the exceptions from this time frame only if thereplacement is needed due to an occurrence beyond the recipient’s control. Therequest for a replacement glucose monitor must be accompanied by the documentationof the reason for the request. Negligence will not be considered a valid reason forexception.Blood Glucose Test or Reagent Strips and Lancets (A4253, A4259)Blood glucose test or reagent strips for home blood glucose monitor, along withlancets, will be considered for beneficiaries diagnosed as having either Type 1, Type 2,or Gestational Diabetes Mellitus. Blood glucose test or reagent strips must beprescribed as medically necessary by the primary physician, and at least two of thefollowing medical criteria must be met:• Home blood glucose monitoring is required two or more times a day.• Physician identifies or diagnoses a recurrence in the recipient’s symptoms(hyperglycemia, hypoglycemia) that may be prevented, delayed, or controlled byself-monitoring the blood sugar.April 2005 14-5