Clinical Policy: High Dollar Limits - Lancets and Alcohol Swabs
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Defines quantity limits, approval requirements, and high-dollar limit override policy for lancets and alcohol swabs for Arizona Complete Health Medicaid members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Quantity limit approval criteria
Covered when ALL of the following are met
No overrides for high dollar limit of $26.00; approval duration: 1 year
No overrides for high dollar limit of $15.00; approval duration: 1 year
Continuation of previously authorized supplies
Covered when ANY of the following are met
Approval duration: 1 year
Approval duration: 1 year
Coverage for lancets and alcohol swabs is available only when all specified approval and documentation requirements are met. For lancets, an approval on file for blood glucose testing strips of more than 100 per 30 days is required and the provider must document medical necessity for requests that exceed the standard limit of 7 lancets per day. For alcohol swabs, an approval on file requiring injections or blood glucose testing of more than 100 per 30 days is required and the provider must document medical necessity for requests exceeding the standard limit of 7 alcohol swabs per day. When authorized, approvals are issued for up to 1 year.
Providers must submit supporting documentation to demonstrate that the member meets the approval criteria; acceptable documentation may include office chart notes and laboratory results. Prior approval is required when thresholds are exceeded (for example, blood glucose testing or injections >100 per 30 days or requests exceeding the daily limit of 7 lancets or alcohol swabs). Continued coverage may be granted for members already authorized under a previous review, with approvals valid for up to 1 year.
Blood glucose testing requiring >100 testing strips per 30 days or injections requiring >100 injections per 30 days — approval and medical necessity requirements
Approval and medical necessity requirements for requests that exceed standard quantity limits
No overrides for high dollar limit of $26.00; approval duration: 1 year
No overrides for high dollar limit of $15.00; approval duration: 1 year
Covered Indications
Blood glucose testing requiring >100 testing strips per 30 days or injections requiring >100 injections per 30 days — approval and medical necessity requirements
Approval and medical necessity requirements for requests that exceed standard quantity limits
No overrides for high dollar limit of $26.00; approval duration: 1 year
No overrides for high dollar limit of $15.00; approval duration: 1 year
Frequency and Quantity Limits
Coding and Quantitative Thresholds
Provider Actions and Requirements
Prior authorization required for quantities above thresholds
Prior approval is required when blood glucose testing strips or injections exceed 100 per 30 days and when requests exceed the standard limit of 7 lancets or 7 alcohol swabs per day; approvals are issued for up to 1 year.
No step therapy beyond quantity/prior approval rules
No step therapy requirements are specified in this policy beyond the quantity limits and the prior approval requirements for elevated supplies.
Submit supporting documentation with requests
Provider must submit documentation supporting that the member has met all approval criteria; documentation may include office chart notes and lab results.
- Include office chart notes as applicable
- Include relevant laboratory results when available
Denial risk for excess quantity or high‑dollar requests
Requests that exceed the numeric limits or the policy's high-dollar thresholds without required documentation or prior authorization are eligible for denial and will not be overridden.
- No overrides permitted for lancets with a high-dollar amount of $26.00
- No overrides permitted for alcohol swabs with a high-dollar amount of $15.00
Ordering and documentation requirements when thresholds are exceeded
When ordering, the provider must submit supporting documentation (office chart notes and lab results may be included); prior approval is required when the thresholds (>100 per 30 days or >7 per day) are exceeded.
- Document medical necessity for requests greater than 7 per day
- Provide evidence of need for >100 tests/injections per 30 days to support approval
- Expect approvals to be issued for up to 1 year when granted
Ordering Requirements
Ordering requires documentation and prior approval when thresholds exceeded
When ordering supplies above the stated thresholds, the provider must submit supporting clinical documentation; prior approval is required for quantities >100 per 30 days or >7 per day and approvals are valid for 1 year.
Provider Guidance (Actions & Documentation)
Submit clinical documentation with requests
Provider must submit supporting documentation demonstrating the member meets all approval criteria; documentation may include office chart notes and lab results.
Denial risk for excess quantity or high‑dollar requests
Requests exceeding quantity limits without required prior approval and documentation of medical necessity, or requests that exceed the specified high‑dollar limits, will not be overridden and are subject to denial.
- Lancets: no overrides for high‑dollar limit of $26.00.
- Alcohol swabs: no overrides for high‑dollar limit of $15.00.
Definitions
Not Covered
Overrides for expenditures that exceed the specified high-dollar limits are not permitted. Specifically, there are no overrides for the $26.00 high-dollar limit for lancets and no overrides for the $15.00 high-dollar limit for alcohol swabs; requests exceeding these dollar thresholds will not be approved.
Background
This policy implements quantity limits on lancets and alcohol swabs tied to blood glucose testing or injections to manage utilization and high-dollar claims. The intent is to require an approval on file for testing or injections exceeding 100 per 30 days and documentation of medical necessity for requests above the standard limit of 7 per day, while prohibiting any overrides for specified high-dollar thresholds.
Revision History
Policy became effective for Arizona Complete Health Medicaid: Clinical Policy AZ.CP.PMN.1018 implementing quantity limits and high-dollar limits for lancets and alcohol swabs.
Policy last reviewed (Last Review Date) to confirm criteria and limits; approval durations and high-dollar limits affirmed.
New criteria created for items that require quantity limits (creation date recorded as 11.25).
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