Diabetes Prevention Program
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Defines coverage, eligibility, provider recognition, exclusions, and billing/prior authorization guidance for the Medicare Diabetes Prevention Program (MDPP) for Neighborhood Health Plan of Rhode Island Medicare Duals (FIDE) and CO-DSNP lines of business. Excludes certain Medicaid and commercial lines.
Policy reviewed and approved on 10/08/25; no material clinical or coverage changes were made.
Coverage Summary
Overview: Medicare Diabetes Prevention Program (MDPP) is covered with criteria for eligible INTEGRITY for Duals (FIDE) and Duals CONNECT (CO-DSNP) members per policy I-008. Effective date: 10/08/25; Last review: 10/08/25.
Member Eligibility and Program Continuation Criteria
Member Eligibility (Covered when ALL of the following are met)
Members must meet all of the following criteria:
ALL of the following
Qualifying glucose test (one required)
- Hemoglobin A1c between 5.7% and 6.4%A1c 5.7% - 6.4%
- Fasting plasma glucose 110-125 mg/dLFasting plasma glucose 110-125 mg/dL
- 2-hour plasma glucose 140-199 mg/dL (oral glucose tolerance test)2-hour plasma glucose 140-199 mg/dL
- Have a body mass index (BMI) of 25 or more (BMI of 23 or more if Asian)BMI >=25 (>=23 if Asian)
Member's weight and height must be measured in-person at the first core session and used to calculate BMI.
- Never been diagnosed with type 1 or type 2 diabetes (gestational diabetes exception allowed)
- Never been diagnosed with End-Stage Renal Disease (ESRD)
- Never participated in the Medicare Diabetes Prevention Program (members are only eligible once-per-lifetime)Once-per-lifetime
- Enrolled in a Medicare line of business covered by this policy (INTEGRITY for Duals (FIDE) or Duals CONNECT (CO-DSNP))
Continuation / Discontinuation Rules
Operational continuation rules noted in policy:
ALL of the following
- Continuation if diabetes develops: If the member develops diabetes while receiving MDPP services, they can continue with the program
- Discontinuation if ESRD develops: If the member develops ESRD while receiving MDPP services, they cannot continue with the program
Provider Actions & Requirements
Document glucose test within 12 months
Provider must document a qualifying Hemoglobin A1c, fasting plasma glucose, or 2‑hour plasma glucose within 12 months prior to the member's first core session. Acceptable thresholds are: A1c 5.7%–6.4%; fasting plasma glucose 110–125 mg/dL; 2‑hour plasma glucose (OGTT) 140–199 mg/dL.
Measure and record height and weight in-person
Member weight and height must be measured in-person at the first core session and used to calculate BMI; this measurement is required to confirm eligibility (BMI ≥25, or ≥23 for Asian members).
Provider recognition requirement
MDPP services must be provided by CDC‑approved providers that hold one of the accepted recognition statuses listed below.
- MDPP Interim Preliminary Recognition
- MDPP Preliminary Recognition
- CDC Preliminary Recognition
- CDC Full Recognition
Prior authorization process reference
All CMS and CDC program, provider, and billing requirements for MDPP must be met. Prior authorization request forms are available on Neighborhood's website (Providers > Provider Resources > Forms > list of prior authorization request forms). For assistance, providers can call 1-800-963-1001.
Non-enrollment or disqualifying diagnoses lead to noncoverage
Claims are noncovered when the member has prior participation in MDPP, a prior diagnosis of type 1 or type 2 diabetes, a diagnosis of End‑Stage Renal Disease (ESRD), or is not enrolled in a Medicare line of business covered by this policy.
Coding
| No codes listed |
Background & Definitions
Background: The MDPP provides year-long lifestyle coaching based on a CDC-approved curriculum. The program is delivered in two phases over one year: Phase 1 (months 0–6) with weekly 1-hour in-person or distance learning sessions, and Phase 2 (months 7–12) with monthly 1-hour in-person or distance learning follow-up sessions.
| Term | Definition |
|---|---|
| MDPP | Medicare Diabetes Prevention Program: a year-long, CDC-approved lifestyle coaching program (Phase 1 months 0-6 weekly sessions; Phase 2 months 7-12 monthly sessions) providing ongoing health behavior coaching and education focused on diet, physical activity, and weight loss to prevent or delay onset of type 2 diabetes |
| ESRD | End-Stage Renal Disease: a diagnosis that disqualifies members from MDPP participation (members who develop ESRD while receiving MDPP services cannot continue) |
| CDC recognition | Provider recognition status from the Centers for Disease Control and Prevention required to furnish MDPP services; accepted recognitions include MDPP Interim Preliminary, MDPP Preliminary, CDC Preliminary, and CDC Full Recognition |
Revision History
Policy reviewed and approved with last review and effective date 10/8/25; no clinical policy statement changes noted in document.
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