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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that The quantity of test strips (code A4253) and lancets (code A4259) that are covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. Coverage of testing supplies is based on the following guidelines: Usual Utilization For a beneficiary who is not currently being treated with insulin injections, up to 100 test strips and up to 100 lancets every 3 months are covered if the basic coverage criteria (1)-(2) (above) are met. For a beneficiary who is currently being treated with insulin injections, up to 300 test strips and up to 300 lancets every 3 months are covered if basic coverage criteria (1)-(2) (above) are met. High Utilization For a beneficiary who is not currently being treated with insulin injections, more than 100 test strips and more than 100 lancets every 3 months are covered if criteria (a) - (c) below are met. For a beneficiary who is currently being treated with insulin injections, more than 300 test strips and more than 300 lancets every 3 months are covered if criteria (a) - (c) below are met. Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and supplies are met; and, Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described above; and, Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual utilization amounts, the treating practitioner must verify adherence to the high utilization testing regimen. If neither basic coverage criterion (1) or (2) is met, all testing supplies will be denied as not reasonable and necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria (a) - (c) are not met, the amount in excess will be denied as not reasonable and necessary. CONTINUOUS GLUCOSE MONITORS (CGM) CGM devices covered by Medicare under the DME benefit are defined in CMS Ruling 1682R as therapeutic CGMs. Refer to the Non-Medical Necessity Coverage and Payment Rules in the LCD-related Policy Article for additional information. Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met:
The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and, The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and, The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and, Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not reasonable and necessary. The supply allowance (code K0553) is billed as 1 Unit of Service (UOS) per thirty (30) days. Only one (1) UOS of code K0553 may be billed to the DME MACs at a time. Billing more than 1 UOS per 30 days of code K0553 will be denied as not reasonable and necessary. Therapeutic CGM devices replace a standard home blood glucose monitor (HCPCS codes E0607, E2100, E2101) and related supplies (HCPCS codes A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259). Claims for a BGM and related supplies, billed in addition to an approved CGM device (code K0554) and associated supply allowance (code K0553), will be denied. Refer to the Coding Guidelines in the LCD-related Policy Article for additional information. All therapeutic CGM devices billed to Medicare using HCPCS code K0554 must be reviewed for correct coding by the Pricing, Data Analysis and Coding contractor (PDAC). Continuous Glucose Monitor systems that have not been reviewed and listed on the Product Classification List for HCPCS code K0554 will be denied as incorrect coding. Refer to the Coding Guidelines in the LCD-related Policy Article for additional information. Lancets (code A4259), blood glucose test reagent strips (code A4253), glucose control solutions (code A4256) and spring powered devices for lancets (code A4258) are covered for beneficiaries for whom the glucose monitor is covered. For glucose test strips (code A4253), 1 unit of service = 50 strips. For lancets (code A4259), 1 unit of service = 100 lancets. Blood glucose test or reagent strips that use a visual reading and are not used in a glucose monitor must be coded A9270 (noncovered item or service). Do not use code A4253 for these items. You can find this information in Medicare's Local Coverage Determination (LCD): Glucose Monitors (L33822) and Local Coverage Article Glucose Monitor - Policy Article (A52464).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health plan contract says that enrollees must pay 0% cost sharing limited to diabetic testing supplies (meters, strips, and lancets) obtained through the pharmacy for a LifeScan branded product (OneTouch Verio Flex, OneTouch Verio Reflect, OneTouch Verio, OneTouch Ultra Mini and OneTouch Ultra 2). All test strips will also be subject to a quantity limit of 204 per 30 days. Therapeutic Continuous Glucose Monitoring (CGM) products are covered from Abbott (Freestyle Libre/Libre II) and Dexcom (G5 and G6) - and when obtained through the pharmacy, are subject to prior authorization. You can find this information in Chapter 4 on page 70 of the plan's 2021 Evidence of Coverage.