CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Glucose Monitoring Home - Non-OneTouch Brand

Defines coverage and prior authorization requirements for non-OneTouch branded home blood glucose monitors for Medicare Advantage members of Blue Cross & Blue Shield of Rhode Island; commercial members have no brand limitation.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyGlucose Monitoring Home - Non-OneTouch Brand

Policy CodePolicy N/A

Change TypeNo material change

Effective Date06|01|2021

Next Review DateN/A

Key ActionObtain prior authorization from BCBSRI Pharmacy Benefit Management for non-OneTouch branded products submitted for Medicare Advantage members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OneTouch preferredPreferred brand for Medicare Advantage members

PA requiredNon-OneTouch requests for Medicare Advantage

500/200Test strip quantity limits

KX/KSClaim modifier requirement

Coverage Criteria

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Coverage criteria for non-OneTouch home glucose monitors

Covered when ALL of the following are met for Medicare Advantage members

Medicare Advantage applicability: Request is for a Medicare Advantage Plan member (policy applies to Medicare Advantage only).

For Commercial Products there is no brand limitation; this Medicare Advantage brand limitation does not apply to commercial lines.

Preferred brand expectation: The preferred brand for Medicare Advantage members is OneTouch; requests for non-OneTouch branded blood glucose monitors (including strips) are allowed only when the coverage criteria below are met.

See OneTouch product examples and quantity limits in the Coding section.

PBM clinical criteria and prior authorization: Documentation shows the requested non-OneTouch device meets the clinical criteria on the BCBSRI Pharmacy Benefit Management (PBM) website and prior authorization has been obtained from the PBM before claim submission.

Refer to covermymeds.com or contact the BCBSRI PBM (phone or fax) for submission and criteria details.

Claims submission requirements: Claims include the appropriate HCPCS and NDC for the device dispensed and required CMS modifiers as applicable (KX for insulin-treated members or KS for non-insulin-treated where specified).

Claims and prior authorization documentation must reference the device dispensed; follow PBM submission instructions.

For Commercial Products there is no benefit limitation regarding brands of home blood glucose monitors; all brands are covered. The Medicare Advantage brand limitation described in this policy applies only to Medicare Advantage members and does not apply to commercial members.

Requests for non-OneTouch branded home blood glucose monitors for Medicare Advantage members must meet the BCBSRI Pharmacy Benefit Management Program clinical criteria and obtain prior authorization via the PBM (phone: 1-800-693-6651, fax: 855-212-8110, or covermymeds.com). Non-OneTouch products requested for Medicare Advantage members that do not meet PBM clinical criteria or for which prior authorization has not been obtained are not covered.

Medical Necessity for Non-OneTouch Products

DME medical necessity for non-OneTouch products

Medical necessity for non-OneTouch branded equipment requires meeting PBM criteria and prior authorization for Medicare Advantage members.

PBM criteria met: Documentation shows the device meets clinical criteria as outlined by the BCBSRI Pharmacy Benefit Management Program on covermymeds.com.

BCBSRI PBM clinical guidelines determine approval; consult the PBM site for specific requirements.

Prior authorization obtained: Prior authorization approval from the BCBSRI PBM is present prior to claim submission.

Contact the BCBSRI PBM at 1-800-693-6651, fax 855-212-8110, or submit via covermymeds.com.

Coding and Supply Limits

Covered HCPCS Codes for non-OneTouch when criteria metHCPCSCovered

A4253	Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
A4259	Lancets, per box of 100
A4271	Integrated lancing and blood sample testing cartridges for home blood glucose monitor, per month (New Code Effective 4/1/2024)
E0607	Home blood glucose monitor
E2100	Blood glucose monitor with integrated voice synthesizer
E2101	Blood glucose monitor with integrated lancing/blood sample
E2104	Home blood glucose monitor for use with integrated lancing/blood sample testing cartridge (New Code Effective 4/1/2024)

Test strip/lancet limits

Insulin-dependent test strips/lancets500 units per 3 months

Non–insulin-dependent test strips/lancets200 units per 3 months

Timeframe for limitsLimits apply per 3-month period

Provider Actions and Requirements

Prior Authorization

Prior authorization required for non-OneTouch brands

Prior authorization is required for requests for non-OneTouch branded home blood glucose monitors for Medicare Advantage members. Contact the BCBSRI Pharmacy Benefit Management vendor by phone, fax, or via covermymeds.com to initiate prior authorization.

Phone: 1-800-693-6651
Fax: 855-212-8110
Online: covermymeds.com

Step Therapy

OneTouch is the preferred/limited benefit

OneTouch is the preferred brand for Medicare Advantage members; non-OneTouch branded meters and strips are limited benefits and require meeting PBM clinical criteria and prior authorization before coverage is allowed.

OneTouch is the preferred brand under Medicare Advantage.
Non-OneTouch requests must meet BCBSRI PBM clinical criteria and have prior authorization.

Documentation Required

Claims and prior authorization documentation

Claims and prior authorization submissions must include the HCPCS and the NDC for the device dispensed; prior authorization requests may be submitted by phone, fax, or via covermymeds.com as directed by the BCBSRI PBM.

Include HCPCS and NDC on claims to ensure correct claims processing.
Submit prior authorization requests to BCBSRI PBM: phone 1-800-693-6651, fax 855-212-8110, or covermymeds.com.

Denial Risk

Denial risk if prior authorization or PBM criteria not met

Requests for non-OneTouch branded home blood glucose monitors for Medicare Advantage members will be denied if BCBSRI PBM clinical criteria are not met or if prior authorization was not obtained.

Non-OneTouch products without PBM criteria approval or prior authorization are not covered for Medicare Advantage members.

Documentation Requirements

Billing Rule

Include HCPCS and NDC on PBM prior auth and claims

When submitting PBM prior authorization documentation and when filing claims for non-OneTouch items, include both the appropriate HCPCS code and the NDC for the device dispensed.

Covered HCPCS codes when criteria are met include A4253, A4259, A4271, E0607, E2100, E2101, and E2104.
File claims with the HCPCS and NDC to ensure correct processing.

Rental and Purchase Rules

Item	Rule / Notes
Home blood glucose monitors (E0607, E2100, E2101, E2104)
Policy: Rental vs. purchase rules not specified in this document; benefits may vary by group/contract. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable durable medical equipment benefits/coverage.
Blood glucose test strips (A4253)
Quantity/limits: See Coding section for test strip limits; claims must be filed with the HCPCS and NDC for the device dispensed.
Lancets (A4259)
Note: There is no benefit limitation regarding brands of lancets.
Integrated lancing and blood sample testing cartridges (A4271)
New code effective 4/1/2024; covered when medical criteria are met and prior authorization obtained for Medicare Advantage requests.

Definitions

Insulin-treated (definition)

Insulin-treated definitionMember receiving insulin injections to treat their diabetes; oral medications do not qualify as insulin treatment.

ScopeApplies when determining eligibility for insulin-dependent supply limits and modifier use

ClarificationInsulin is not available in oral form; members on oral hypoglycemics are not considered insulin-treated

Blood glucose monitor with integrated voice synthesizer (definition)

Device descriptionDevice that converts glucose results to sound output in addition to display.

FunctionProvides both visual display and digitized audio readout of blood glucose results

Use caseUseful for members with visual impairment who require audible results

Blood glucose monitor with integrated lancing (definition)

Device descriptionDevice with built-in lancing/blood sampling rather than a separate accessory.

FunctionIntegrates the lancing device into the glucose monitor for sample collection

Coding relevanceRelated HCPCS codes include E2101 and new cartridge code A4271 (see coding section)