CurrentHighmark Blueshield NenyPolicy N/A

Prior authorization criteria for diabetic blood glucose testing supplies

Form and criteria for prior authorization of diabetic blood glucose monitoring supplies (test strips, meters, related supplies) for Highmark BlueShield members; applies to providers requesting coverage and affects member eligibility and prescribing clinicians.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPrior authorization criteria for diabetic blood glucose testing supplies

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with supporting chart notes and fax to 1-866-240-8123 (or mail to the SPECARE address).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6clinical screening questions on the form (items 1–6)

13numbered clinical items (items 1–13) collected on form

1-866-240-8123fax number for prior authorization submission

120 Fifth Ave, Pittsburghmailing address for form submission

Coverage and Medical Necessity Criteria

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Medical necessity indications

Covered when ALL of the following are met and documented on the form (as applicable):

core_requirements: Member has a diagnosis of diabetes mellitus (item 1) AND treating practitioner documents sufficient training and issues appropriate prescription for supplies and testing frequency (item 4) AND treating practitioner has had an in-person or Medicare-approved telehealth visit within last 6 months (item 9) AND will continue visits every 6 months after initial prescription to assess adherence (item 10)

Chart notes required to support answers.

hypoglycemia_indications: Member has documented history of poorly controlled diabetes or problematic hypoglycemia (items 3, 7a, 7b, 8) OR is insulin-treated and/or uses an insulin pump (items 5, 6a) OR has severe visual or manual dexterity impairment requiring a special monitoring system (items 12, 13)

If yes, include chart notes documenting episodes, pump use, visual or manual impairment.

Payment for services requested on this form remains conditional on member eligibility and the specific terms of the member’s benefit plan. The form itself does not add or override plan terms; providers must follow plan coverage rules and submit supporting clinical documentation as required.

The form does not enumerate specific circumstances that are considered not medically necessary. Absence of explicit exclusions on the form does not imply automatic coverage — determinations remain subject to the member’s plan provisions and review of submitted clinical evidence.

Key Clinical Thresholds and Definitions

Hypoglycemia glucose thresholds — key values

Level 2 hypoglycemia thresholdBlood glucose less than 54 mg/dL (3.0 mmol/L)

Problematic/frequent severe hypoglycemia thresholdBlood glucose less than 50 mg/dL

Context in formUsed to define recurrent level 2 events and problematic hypoglycemia for prior authorization documentation

Level 2 hypoglycemia

DefinitionRecurrent (more than one) hypoglycemic events with glucose <54 mg/dL (3.0 mmol/L)

Clinical requirementEvents persist despite multiple attempts to adjust medications and/or modify the diabetes treatment plan

DocumentationChart notes must be included to support history of recurrent level 2 events

Level 3 hypoglycemia

DefinitionA hypoglycemic event characterized by altered mental and/or physical state requiring third-party assistance

Associated glucose value noted on formLevel 3 event described in form with glucose referenced as <54 mg/dL (3.0 mmol/L)

DocumentationChart notes must be included to support history of level 3 event when reported

Problematic hypoglycemia — operational definition

Problematic hypoglycemia definitionNocturnal hypoglycemia, hypoglycemic unawareness, or frequent/severe hypoglycemia defined as blood glucose <50 mg/dL

Form itemQuestion 8 specifically asks whether member has experienced problematic hypoglycemia as defined

DocumentationIf yes, include chart notes to support this information

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Submit the completed prior authorization form and all supporting clinical documentation. Fax to 1-866-240-8123 or mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. Submit a separate form for each medication. The prescribing physician (PCP or Specialist) should, in most cases, complete the form. Payment is subject to member eligibility; authorization does not guarantee payment.

Fax: 1-866-240-8123
Mail: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
Submit a separate form for each medication
Prescribing physician (PCP or Specialist) should complete the form

Documentation Required

Document Prior Product Trials

Document prior product trials. Provide a list of other products the member has tried and failed and include chart notes to support previous product failures, intolerance, or contraindications.

Include specific product names and durations tried
Attach chart notes supporting failure/intolerance/contraindication

Documentation Required

Required Clinical Documentation

Include required clinical documentation with the submission. Chart notes should support diagnosis of diabetes mellitus, history of poorly controlled diabetes (for example, unexplained hypoglycemic episodes, hypoglycemic unawareness, suspected postprandial hyperglycemia, recurrent diabetic ketoacidosis), pregnancy/gestational diabetes status when applicable, evidence of training for the member or caregiver on product use (including supplies and blood glucose testing frequency), and any insulin pump use or hypoglycemia events as applicable.

Diagnosis of diabetes mellitus (and pregnancy/gestational diabetes if applicable)
Chart notes supporting poorly controlled diabetes or hypoglycemic events
Evidence of training for member/caregiver and prescription for supplies/testing frequency
Documentation of prior product failures, intolerance, or contraindications

Denial Risk

Documentation and Eligibility May Trigger Denial

Payment is subject to member eligibility and completeness of documentation. Authorization does not guarantee payment; incomplete or missing clinical documentation may result in denial.

Authorization ≠ guarantee of payment
Ensure all clinical documentation is included to avoid denial

Form Purpose and Scope

This prior authorization form collects clinical information needed to evaluate medical necessity for diabetic blood glucose testing supplies. It documents the member’s diagnosis of diabetes mellitus, pregnancy/gestational status, daily testing needs and frequency, history of problematic hypoglycemia (including nocturnal hypoglycemia, hypoglycemic unawareness, or recurrent events), use of insulin or insulin pump therapy, impairments affecting vision or manual dexterity, and provider training and follow‑up visits. Providers must complete all applicable items and include chart notes and other clinical documentation when submitting the form via fax or mail to support the request.