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Decision: unknown

 
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that contract suppliers are not required to furnish a specific brand name item or mode of delivery 
to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. 
You can find this information in the Medicare Claims Processing Manual, Chapter 36, Section 30.4 - 
Prescription for Particular Brand, Item, or Mode of Delivery. 
 
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: For a beneficiary who is not currently being treated with insulin 
administrations, 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 administrations, up to 300 test strips and up to 300 
lancets every 3 months are covered if basic coverage criteria (1)-(2) (above) are met. 
 
For a beneficiary who is not currently being treated with insulin administrations, 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 administrations, more than 300 test strips and 
more than 300 lancets every 3 months are covered if criteria (a)  (c) below are met. 
a. Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and 
supplies are met; and, 
b. 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, 
c. 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. You can find this 
information in Local Coverage Determination (LCD) Glucose Monitors L33822. 
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.