Glucose Monitoring Home - Non-OneTouch Brand
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage criteria for non-OneTouch home glucose monitors
Covered when ALL of the following are met for Medicare Advantage members
For Commercial Products there is no brand limitation; this Medicare Advantage brand limitation does not apply to commercial lines.
See OneTouch product examples and quantity limits in the Coding section.
Refer to covermymeds.com or contact the BCBSRI PBM (phone or fax) for submission and criteria details.
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.
BCBSRI PBM clinical guidelines determine approval; consult the PBM site for specific requirements.
Contact the BCBSRI PBM at 1-800-693-6651, fax 855-212-8110, or submit via covermymeds.com.
Coding and Supply Limits
| 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) |
Provider Actions and Requirements
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
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.
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 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
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.
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. |
Replacement
Definitions
Background
A home blood glucose monitor (glucometer) is a portable, battery-operated device that measures capillary whole blood glucose using reagent test strips and commonly stores results. Some monitors have additional capabilities such as an integrated voice synthesizer (for audible results) or integrated lancing/blood sampling features that combine lancing and sample collection into the device.
Not Covered
NOT COVERED: Non-OneTouch branded home blood glucose monitors (including test strips) requested for Medicare Advantage members when the request does not meet the PBM clinical criteria and when prior authorization has not been obtained from the BCBSRI Pharmacy Benefit Management Program.
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