CurrentCapital BluecrossPolicy N/A

Diabetic Testing Supplies Prior Authorization Criteria Medicare Part B

Defines Capital Blue Cross Medicare Part B prior authorization requirements for diabetic testing supplies (test strips, lancets, meters) and identifies preferred vs nonpreferred products; applies to providers and Medicare Part B members.

Policy Summary

PayerCapital Bluecross

PolicyDiabetic Testing Supplies Prior Authorization Criteria Medicare Part B

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateSep 1, 2025

Key ActionPrior authorization is required for nonpreferred diabetic testing supplies; prescribers must try one preferred Ascensia product and document failure or limitation before a nonpreferred product will be approved.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Part Bprogram applicability

2026year

Onepreferred trial

All testing suppliestarget agents

Pogo addedadmin note

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Coverage Criteria

Prior Authorization Approval Criteria

Evaluation: Diabetic testing supply target(s) will be approved when BOTH of the following are met:

Overall approval logic: Both criteria 1 AND 2 must be satisfied for approval

Criterion 1: One of the following: (a) Information has been provided that the patient has been treated with a diabetes medication within the past 90 days; OR (b) Information has been provided that the patient has been treated with a concomitant drug that may affect blood sugar levels within the past 90 days; OR (c) The patient has gestational diabetes; OR (d) The patient is prediabetic or diabetic90 days for medication/concomitant drug

Criterion 2: The prescriber has provided information indicating the patient has failed or has limitations precluding use of the preferred diabetic testing supply product(s) (as determined by client)

Client-determined preferred products list applies

Continuous glucose monitoring devices are explicitly excluded from this prior authorization program. The program applies to diabetic testing supplies such as test strips, lancets, and meters, but continuous blood glucose monitors (CGMs) are not included in the program.

Coding — Preferred and Nonpreferred Products

Preferred Diabetic Testing Supply GPIsmixedCovered

GPI=94100030006100	Contour/Contour Next Test Strips
GPI=97202010006200	Contour Blood Glucose Monitoring System
GPI=97202010006400	Contour Next One Blood Glucose Monitoring System
GPI=97202010006410	Contour/Contour Next Blood Glucose Monitoring Systems

Nonpreferred Diabetic Testing Supply GPIsmixedNot Covered

GPI=94100030006100	Blood Glucose Test Strips
GPI=94100030006020	Test cartridges
GPI=97202010006200	Blood Glucose Monitoring Device
GPI=97202010006400	Blood Glucose Monitoring Kit
GPI=97202010006410	Blood Glucose Monitoring Kit

Provider Actions and Prior Authorization Workflow

Prior Authorization

Prior Authorization Required for Nonpreferred Products

Prior authorization is required for nonpreferred diabetic testing supplies. One preferred Ascensia product (e.g., Contour/Contour Next test strips or system) must be tried and documented by the prescriber before a nonpreferred product will be authorized.

Preferred products: Ascensia/Contour/Contour Next (GPI examples: 94100030006100; system GPIs: 97202010006200, 97202010006400, 97202010006410).
Nonpreferred products: non-Ascensia blood glucose test strips, cartridges, devices, and kits (see GPI ranges in source).
OneTouch products: covered at 20% coinsurance and do not require PA.

Step Therapy

Preferred-product Trial Required

Step requirement: the prescriber must document a trial of ONE preferred Ascensia product prior to requesting authorization for a nonpreferred diabetic testing supply. Documentation should specify which Ascensia product was used and the clinical rationale for switching to a nonpreferred product.

Definitions

Diabetic testing supplies — definitions for strips, meters, lancets, and CGM exclusion

Blood glucose test stripsTest strips intended for quantitative self-monitoring of blood glucose (SMBG) by people with diabetes; used with compatible meters to measure glucose in blood samples outside the body.

Blood glucose meters (BGM)Portable glucose meters used with test strips to quantitatively measure glucose for SMBG by people with diabetes and in clinical settings.

LancetsSmall, single-use devices used to obtain capillary blood samples for SMBG when used with test strips and meters.

Continuous glucose monitors (CGMs)Continuous glucose monitors are explicitly excluded from this program and are not covered as part of this diabetic testing supplies policy.

Intended useStrips, lancets, and meters are intended for use outside the body for self-monitoring of blood glucose (SMBG) at home and by healthcare professionals in clinical settings to aid monitoring of diabetes control.

Background

Blood glucose test strips, lancets, and meters are used for quantitative self‑monitoring of blood glucose by people with diabetes and in clinical settings. This program covers those diabetic testing supplies for Medicare Part B members and defines prior authorization requirements for nonpreferred products; it does not apply to continuous glucose monitoring systems.

Policy Summary

PayerCapital Bluecross

PolicyDiabetic Testing Supplies Prior Authorization Criteria Medicare Part B

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateSep 1, 2025

SourceLink

On This Page

Prescriber must provide evidence of trial of ONE preferred Ascensia product (e.g., Contour/Contour Next strips or system).
If the patient could not use the preferred product, the prescriber must describe the limitation or failure that precludes its use.

Documentation Required

Documentation Required from Prescriber

Provider must supply evidence that the patient meets the authorization clinical trigger and that the preferred-product trial requirement is met. Acceptable documentation includes medication history showing treatment with a diabetes medication or a concomitant drug affecting blood sugar within the past 90 days, or documentation of gestational diabetes, prediabetes, or diabetes.

Clinical trigger: treatment with a diabetes medication within the past 90 days, OR treatment with a concomitant drug that may affect blood sugar within the past 90 days, OR diagnosis of gestational diabetes, prediabetes, or diabetes.
Documentation of the preferred Ascensia product trial and clinical reason for failure/limitation of the preferred product.

Denial Risk

Denial Triggers for Prior Authorization

Requests for nonpreferred diabetic testing supplies may be denied if BOTH the clinical trigger (see documentation requirements) and the preferred-product trial (ONE preferred Ascensia product) are not met or not adequately documented.

Denial may occur when clinical evidence of diabetes treatment or qualifying diagnosis within the past 90 days is absent.
Denial may occur when prescriber fails to document trial of ONE preferred Ascensia product or adequate rationale why preferred product cannot be used.