CurrentmhnPolicy CP.PMN.215

Non-Preferred Blood Glucose Monitors/Test Strips

Defines prior authorization and medical necessity criteria for non-preferred blood glucose monitors and test strips for Medicaid members; excludes continuous glucose monitors (see separate policy).

Policy Summary

Payermhn

PolicyNon-Preferred Blood Glucose Monitors/Test Strips

Policy CodePolicy CP.PMN.215

Change TypeCriteria updatere-authorization clarified

Effective DateDec 1, 2019

Next Review Date

Key ActionSubmit prior authorization with documentation showing inability to use preferred products and that requested quantity does not exceed plan limits.

SourceLink

POLICY UPDATE CHANGES

Added requirement that requested quantity does not exceed the health-plan quantity limit (if applicable).

Clarified that re-authorization is not permitted and members must meet the initial approval criteria for continued therapy.

Appendix B preferred products updated (replaced OneTouch with Accu-Chek; later added True Metrix products).

12 moInitial approval duration

Not permittedRe-authorization

MedicaidLine of Business

NCApplicable state

Coverage / Medical Necessity Criteria

Initial Therapy — Non-preferred blood glucose monitors/test strips are medically necessary when ALL of the following are met:

Non-preferred blood glucose monitors/test strips are medically necessary when ALL of the following are met:

Initial Approval Criteria

Examples of inability to use preferred products: a) impaired vision requiring a blood glucose monitor with audio; b) limited dexterity (e.g., arthritis) requiring larger test strips, a monitor with larger buttons, or pre-loaded lancet drum with no individual lancets; c) current insulin pump incompatible with preferred products.
Quantity limit: 2) Requested quantity does not exceed the health-plan quantity limit (if applicable).

Approval duration is 12 months for initial approvals.12 months

Policy Summary

Payermhn

PolicyNon-Preferred Blood Glucose Monitors/Test Strips

Policy CodePolicy CP.PMN.215

Change TypeCriteria updatere-authorization clarified

Effective DateDec 1, 2019

Next Review Date

Key ActionSubmit prior authorization with documentation showing inability to use preferred products and that requested quantity does not exceed plan limits.

SourceLink

On This Page

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Continuation Therapy — Continued therapy requests:

Continued therapy requests:

Re-authorization is not permitted. Members seeking continued access to non-preferred monitors/test strips must meet the initial approval criteria again.not applicable

If the request is for a continuous glucose monitor (CGM), coverage is governed by policy CP.PMN.214 rather than this policy. Refer CGM requests to that policy for prior authorization and medical necessity determinations.

Requests that do not document an inability to use the health-plan preferred blood glucose monitor(s) and/or test strip(s) (for example, evidence of impaired vision, limited dexterity, or pump incompatibility) are not supported as medically necessary under this policy. Similarly, requests that exceed the health-plan quantity limit (if applicable) are not supported as medically necessary.

What Providers Must Do / Watch For

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-preferred blood glucose monitors and test strips. Continuous glucose monitor requests should be routed to CP.PMN.214.

Prior authorization required for non-preferred blood glucose monitors and test strips
For continuous glucose monitors, see CP.PMN.214

Documentation Required

Required Documentation

Provider must submit documentation (such as office chart notes, lab results, or other clinical information) supporting that the member has met all approval criteria. This documentation must demonstrate the medical reason the preferred products cannot be used.

Examples: office chart notes, lab results, device compatibility information, notes on vision or dexterity limitations

Denial Risk

Insufficient Documentation May Lead to Denial

Requests lacking documentation that the member cannot use preferred blood glucose monitor/test strips (for example, no evidence of impaired vision, no documentation of limited dexterity, or no incompatibility with an insulin pump) may be denied.

No evidence of impaired vision or need for audio-enabled meter
No documentation of limited dexterity (e.g., arthritis) requiring larger strips or pre-loaded lancet drum
No documentation of incompatibility with member's insulin pump

Denial Risk

Quantity Limits

Requests that exceed the health-plan quantity limit (when applicable) may be denied. Ensure the requested quantity is within the plan's limits before submitting the prior authorization request.

Requested quantity must not exceed health-plan quantity limit
If quantity limits apply, indicate the clinical justification for amounts beyond limits (if applicable)

Note

Preferred Alternatives

Preferred alternatives are listed in Appendix B; providers should consider preferred products before requesting non-preferred items.

See Appendix B for preferred products (e.g., FreeStyle, Accu-Chek, True Metrix families)

Key Terms

CGM — definition for continuous glucose monitoring (CGM)

TermCGM

DefinitionContinuous glucose monitoring

Policy noteRequests for continuous glucose monitors are governed by CP.PMN.214 (see related policies).

SMBG — definition for self-monitoring of blood glucose (SMBG)

TermSMBG

DefinitionSelf-monitoring of blood glucose

ContextSMBG (blood glucose monitors and test strips) are addressed in this policy when non-preferred products are requested; preferred alternatives are listed in Appendix B.

Background

Blood glucose monitors and test strips are used to monitor blood glucose in patients with diabetes mellitus and to guide treatment decisions. Device selection should consider patient circumstances and needs (for example, audio capability for impaired vision or larger buttons/strips for limited dexterity). Continuous glucose monitoring is addressed under a separate policy (CP.PMN.214).