For services prior to September 15, 2008, see medical policy B-46.

The Diabetes Insurance mandate West Virginia: § 33-16-16;C.S.R. §114-52-1 et seq., defines the equipment/supplies and Self-Management Education for the treatment/management of diabetes for insulin and non-insulin dependent persons with diabetes and those with gestational diabetes, if medically necessary because of diabetes and prescribed by a licensed physician, or upon written order by a licensed physician, are to be covered.

Equipment and supplies: Equipment and supplies for the treatment/management of diabetes for insulin and non-insulin dependent persons with diabetes and those with gestational diabetes, diabetes and prescribed by a licensed physician, or upon written order by a licensed physician, are to be covered. Equipment and supplies include:

• blood glucose monitors; (A9275, E0607, E2100, E2101)
• monitor supplies; (A4233-A4236, A4244-A4248, A4253-A4259, E0620, e.g., Lasette, E1399)
• insulin; (J1815, J1817, S5550, S5551, S5552, S5553, S5565, S5566)
• injection aids; (A4210-A4211, S5560, S5561 S5570, S5571)
• syringes, insulin infusion devices and related supplies; (A4206-A4209, A4213, A4215, S8490, A4222-A4232, A9274, E0784, K0552, K0601-K0605)
• pharmacological agents for controlling blood sugar; (J1610, S5000, S5001)
• orthotics;
• urine ketone testing strips; (A4250, A4252)
• urine micro albumin test;
• blood pressure monitoring device; (A4660, A4663, A4670)
• podiatric appliances and therapeutic footwear; and
• orthopedic appliances including canes, crutches and walkers,
• and other items as may be necessary, (A4369, A4371, A4405, A4406, A4456 and A5120)

The physician prescription for blood glucose monitor supplies must state a diagnosis of diabetes, whether or not the patient is being treated with insulin injections, the item/supplies/accessories needed, the quantity to be dispensed, and the frequency with which the patient should use them. A prescription that merely states, "as needed," should not be considered valid for diabetic supplies. A prescription will be valid for six months, at which time the prescription must be renewed in order for the patient to continue receiving test strips and lancets. Reflectance colorimeter devices used for measuring blood glucose levels in clinical settings are not covered as durable medical equipment for patient use in the home because their need for frequent professional recalibration makes them unsuitable for home use. However, some types of blood glucose monitors which use a reflectance meter specifically designed for home use by diabetic patients may be covered as durable medical equipment.

There is also a blood glucose monitoring system designed especially for use by those with visual impairments. The monitors used in such systems are identical in terms of reliability and sensitivity to the standard blood glucose monitors (E0607). They differ by having such features as voice synthesizers (E2100), automatic timers, and specially-designed arrangements of supplies and materials to enable the visually-impaired to use the equipment without assistance. These special glucose monitoring systems are covered if the patient has a diagnosis of diabetes and, the physician prescribing the device certifies that the patient has a visual impairment severe enough to require use of this special monitoring system.

The closed-loop blood glucose control device (CBGCD) is a hospital bedside device designed for short term management of patients with insulin-dependent diabetes mellitus (Type I). Its primary use, which is generally limited to a 24-48 hour period, is for the stabilization of these patients during periods of stress, e.g., trauma, labor and delivery, and surgery.

The monitoring of the CBGCD is considered an integral part of a doctor’s medical care and is not eligible as a distinct and separate service. If the monitoring of the CBGCD is reported on the same day as medical care and the charges are itemized, combine the charges and pay only the medical care. Payment for the medical care performed on the same date of service includes the allowance for the monitoring. A participating, preferred, or network provider cannot bill the member separately for the monitoring in this case.

If the monitoring of the CBGCD is performed independently, process it under the appropriate codes).

Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the monitoring of the CBGCD. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

Insulin pumps (A9274, E0784) are covered only when physician documentation indicates that standard insulin injections have failed to control the diabetes. In these instances, insulin pump initiation with instruction in initial use of the pump (S9145) may also be reimbursed.

A deluxe device is eligible only when the patient's inability to use a standard device can be established. In these instances, the deluxe device should be the most appropriate one that can be safely provided to the patient.

NOTE: Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

ORTHOTICS

Orthotics protect, restore, or improve function with orthopedic appliances or apparatus which support, align, prevent or correct deformities, or improve the function of movable parts of the body. For diabetic patients, therapeutic (orthotic) shoes may be necessary. Diabetic shoes (A5500-A5507) and the Lang Medical Shoe (L2999), foot pressure off-loading/supportive devices (A9283), inserts (A5510, A5512, A5513), and/or modifications to those shoes are eligible when the following criteria are met:

1. The patient has diabetes mellitus, and

2. The patient has one 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.

For patients meeting these criteria, coverage is limited to one of the following within one calendar year:

1. One pair of custom-molded shoes (A5501) and 2 pairs of inserts (A5510, A5512, A5513); or;
2. One pair of depth shoes (A5500) and 3 pairs of inserts (A5510, A5512, A5513)(not including the non-customized removable inserts provided with such shoes).

A modification of a custom-molded or depth shoe will be covered as a substitute for an insert.

A deluxe feature (A5508) does not contribute to the therapeutic function of the shoe; and, therefore, is not covered. A participating, preferred, or network provider can bill the member for the denied deluxe features. It may include, but is not limited to style, color, or type of leather.

Self-Management Education: All policies shall also include coverage for diabetes self-management “education” (98960, 98961, 98962, G0108, G0109). “Education” is limited to visits:

• Medically necessary upon the diagnosis of diabetes;
• Under circumstances whereby a doctor identifies a significant change in the person’s condition that calls for changes in that person’s self management; and
• Where a licensed physician has identified a new medication or process: provided, that coverage for reeducation or refresher education shall be limited to $100 annually.
• Education may be part of an office visit provided by the physician, licensed pharmacist, a certified diabetes educator or registered dietician (MNT - 97802, 97803, 97804, G0270, G0271).
• Application of deductibles and coinsurance is permitted provided it is applied on an equal basis other coverage.

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.

FEP covers insulin, needles, and disposable syringes for the administration of covered medications. FEP does cover  nutritional counseling for up to 4 visits per year when billed by a covered provider. FEP covers diabetic educators, dieticians, and nutritionists who bill independently only as part of a covered diabetic education program. FEP covers dieticians and nutritionists who bill independently for nutritional counseling. FEP does not cover shoes and over-the-counter orthotics, arch supports, heel pads, and heel cups.

The Diabetes Insurance mandate West Virginia: § 33-16-16;C.S.R. §114-52-1 et seq.,