Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0520 - Glucose Monitors and Diabetic Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and limitations of coverage
			 and medical appropriateness:
(a) The Division
			 may cover home blood glucose monitors and related diabetic supplies for clients
			 with diabetes who can self-monitor blood glucose (SMBG) or be monitored with
			 assistance;
(b) Coverage of home
			 blood glucose monitors is limited to clients meeting all of the following
			 conditions:
(A) The client has diabetes that
			 is being treated by a practitioner; and
(B) The glucose monitor and related
			 accessories and supplies have been ordered by a practitioner who is treating
			 the client's diabetes; and
(C) The
			 client or caregiver has successfully completed a structured education and
			 feedback program for self-monitoring of blood glucose and is scheduled to begin
			 training in the use of the monitor, test strips, and lancing devices;
			 and
(D) The client or caregiver is
			 capable of using the test results to assure the client's appropriate glycemic
			 control; and
(E) The device is
			 designed for home use;
(c) Home blood glucose monitors with special
			 features (E2100 or E2101) may be covered for clients who meet the basic
			 coverage criteria (1)(b)(A)-(E) of this rule and the following:
(A) For code E2100, the treating practitioner
			 certifies that the client has a severe visual impairment (i.e., best corrected
			 visual acuity of 20/200 or worse) requiring use of this special monitoring
			 system; or
(B) For code E2101, the
			 treating practitioner certifies that the client has an impairment of manual
			 dexterity severe enough to require the use of this special monitoring
			 system;
(d) If a glucose
			 monitor is covered, lancets, blood glucose test reagent strips, glucose control
			 solutions, insulin syringes, and spring powered devices for lancets may also be
			 covered. Coverage limitations for these supplies are as follows:
(A) For A4258, only one spring powered device
			 every six months;
(B) For A4253 and
			 A4259, the provider of the test strips and lancets shall maintain in their
			 records the order from the treating practitioner. The provider shall verify
			 that the client has nearly exhausted their supply, before dispensing more test
			 strips and lancets. The amount of test strips and lancets covered is based on
			 the needs of the client according to the following limitations:
(i) For clients with type 2 diabetes not
			 requiring multiple daily insulin injections, up to 50 test strips (1 unit) and
			 100 lancets (1 unit) at the time of diagnosis;
(ii) For clients with type 2 diabetes who
			 require diabetic medication that may result in hypoglycemia, up to 50 test
			 strips and 100 lancets per 90 days. An additional 50 test strips may be covered
			 with clinical documentation of an acute change in glycemic control or active
			 diabetic medication adjustment;
(iii) For clients with Type 1 diabetes and
			 those with type 2 diabetes requiring multiple daily insulin injections, up to
			 100 test strips and 100 lancets per month;
(iv) For clients with gestational diabetes,
			 up to 150 test strips and 200 lancets per month no longer than 60 days beyond
			 the duration of the pregnancy;
(v)
			 Quantities exceeding these utilization guidelines require prior authorization
			 and may be covered when:
(I) Basic coverage
			 criteria in (1)(b)(A)-(E) for home glucose monitors and related accessories and
			 supplies are met; and
(II) The
			 treating practitioner has seen the client and evaluated their diabetes control
			 within six months prior to ordering quantities of test strips and lancets that
			 exceed the utilization guidelines and has documented in the client's medical
			 record the specific reason for the additional supplies for that particular
			 client; and
(III) If refills of
			 quantities of supplies that exceed utilization guidelines are dispensed, there
			 shall be documentation in the practitioner's records (e.g., a specific
			 narrative statement that adequately specifies the frequency at which the client
			 is actually testing or a copy of the client's log) that the client is actually
			 testing at a frequency that corroborates the quantity of supplies that have
			 been dispensed. If the client is regularly using quantities of supplies that
			 exceed the utilization guidelines, new documentation shall be present at least
			 every six months;
(C) Home blood glucose monitors are subject
			 to a limit of one monitor per two calendar years;
(e) Diabetic supply providers may not
			 dispense a quantity of supplies exceeding a client's expected utilization.
			 Providers shall stay attuned to atypical utilization patterns on behalf of
			 their clients and verify with the ordering practitioner that the atypical
			 utilization is, in fact, warranted. Regardless of utilization, a provider may
			 not dispense more than a three-month quantity of glucose testing supplies
			 (i.e., up to 300 test strips, 300 lancets, and 500 insulin syringes) at a time.
			 Prior authorization (PA) shall be obtained prior to dispensing amounts in
			 excess of these utilization limits;
(f) Providers may contact the treating
			 practitioner to renew an order; however, the request for renewal may only be
			 made with the client's continued monthly use of testing supplies and only with
			 the client's or caregiver's request to the provider for order
			 renewal;
(g) An order refill does
			 not have to be approved by the ordering practitioner; however, a client or
			 their caregiver shall specifically request refills of glucose monitor supplies
			 before they are dispensed. The provider may not automatically dispense a
			 quantity of supplies on a predetermined regular basis, even if the client has
			 "authorized" this in advance;
(h)
			 Purchase fee for a glucose monitor includes normal, low and high-calibrator
			 solution/chips (A4256), a battery (A4233, A4234, A4235 or A4236), and a
			 spring-powered lancet device (A4258);
(i) The following services are not covered as
			 they are not medically necessary or medically appropriate:
(A) Peroxide (A4244), betadine, or phisoHex
			 (A4246, A4247);
(B) Alternate site
			 blood glucose monitors;
(C) Blood
			 glucose monitors and related supplies prescribed on an "as needed"
			 basis;
(D) Blood glucose test or
			 reagent strips that use a visual reading and are not used in a glucose
			 monitor;
(E) Disposable
			 gloves;
(F) Home blood glucose
			 disposable monitors;
(G) Jet
			 injectors;
(H) Insulin delivery
			 devices and related supplies other than those identified in this rule and OAR
			 410-122-0525;
(I) Reflectance
			 colorimeter devices used for measuring blood glucose levels in clinical
			 settings;
(J) Urine test or reagent
			 strips or tablets.