Diabetes self-management training (DSMT) services are covered when these services are furnished by a certified provider who meets certain quality standards. The DSMT program is intended to educate members in the successful self-management of diabetes. The program includes instructions in self-monitoring of blood glucose; education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin-dependent; and motivation for patients to use the skills for self-management.

Diabetes self-management training services (G0108, G0109) are covered for 10 hours of initial training for a member who has been diagnosed with diabetes (250.00-250.93). DSMT must be ordered by the physician or qualified non-physician practitioner who is managing the member’s diabetic condition. Members are eligible to receive 2 hours of follow-up training each calendar year following the year in which they have been certified as requiring initial training.

Initial Training
The initial year for DSMT is the 12 month period following the initial date. Initial training that meets the following conditions will be covered:

• DSMT is furnished to a member who has not previously received initial or follow-up training under code G0108 or G0109;
  
  
• DSMT is furnished within a continuous 12-month period;
  
  
• DSMT does not exceed a total of 10 hours (the 10 hours of training can be done in any
  combination of 1/2 hour increments);
  
  
• With the exception of 1 hour of individual training, the DSMT training is usually furnished in a group setting with the group consisting of individuals who need not all be Medicare beneficiaries, and;
  
  
• The one hour of individual training may be used for any part of the training including insulin training.

Follow-Up Training
Follow-up training is covered under the following conditions:

• No more than two hours individual or group training is provided per member per year;
  
  
• Group training consists of 2 to 20 individuals who need not all be Medicare beneficiaries;
  
  
• Follow-up training for subsequent years is based on a 12 month calendar after completion of the full 10 hours of initial training;
  
  
• Follow-up training is furnished in increments of no less than one-half hour; and
  
  
• The physician or qualified non-physician practitioner treating the member must document in the member's medical record that the member is a diabetic.
  

Coverage Requirements for Individual Training
Training on an individual basis may be covered for a member under any of the following conditions:

• No group session is available within 2 months of the date the training is ordered;
  
  
• The member’s physician or qualified non-physician practitioner documents in the member’s medical record that the member has special needs resulting from conditions, such as severe vision, hearing or language limitations or other such special conditions as identified by the treating physician or non-physician practitioner, that will hinder effective participation in a group training session; or
  
  
• The physician orders additional insulin training.
  
  
• The need for individual training must be identified by the physician or non-physician practitioner in the referral.
  

Payment for DSMT may only be made to any provider that bills for other individual services and may be made only for training sessions actually attended by the member and documented on attendance sheets.

Indications other than those listed above are considered not medically necessary and are ineligible for coverage. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Diabetes self-management training services may be covered only if the treating physician or treating qualified non-physician practitioner who is managing the member’s diabetic condition certifies that such services are needed.  The referring physician or qualified non-physician practitioner must maintain the plan of care in the member’s medical record and documentation substantiating the need for training on an individual basis when group training is typically covered, if so ordered. The order must also include a statement signed by the physician that the service is needed as well as the following:

• The number of initial or follow-up hours ordered (the physician can order less than 10 hours of training);
• The topics to be covered in training (initial training hours can be used for the full initial training program or specific areas such as nutrition or insulin training); and
• A determination that the member should receive individual or group training.

The provider of the service must maintain documentation in file that includes the original order from the physician and any special conditions noted by the physician.

When the training under the order is changed, the training order/referral must be signed by the physician or qualified non-physician practitioner treating the member and maintained in the member’s file in the DSMT’s program records.

See Medicare Advantage Medical Policy Bulletin N-4 for information on Medical Nutrition Therapy.

NOTE:

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 circumstances may warrant individual consideration, based on review of applicable medical records.

Codes G0108 and G0109 should be used to report DSMT.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-2, Chapter 15, Section 300, 300.3, 300.4, 300.5

CMS Online Manual Pub. 100-4, Chapter 18, Section 120.1, 120.2.1

CMS Transmittal 64, CR 5433

CMS Transmittal 1158, CR 5433