Provider Alert! Continuous Glucose Monitors Regular Durable Medical Supplies Limits

Provider Alert!

Provider Alert! Continuous Glucose Monitors Regular Durable Medical Supplies Limits

Date: June 18, 2021

Attention: Endocrinologists, PCPs and DME Providers

Effective Date: August 1, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers of new limits for diabetic supplies processed through the medical benefit for members utilizing continuous glucose monitors [CGM] (HCPCS Code K0553). Diabetic supplies include lancets, test strips, among others.

How this impacts providers: Members with CGMs generally do not require glucose monitoring using traditional supplies. In the event members with CGMs require additional or backup diabetic supplies, TCHP prefers members and providers obtain supplies  through the medical benefit. For emergent situations, members may request to obtain supplies through retail pharmacy benefit.

Prior Authorization is not required for requests made within the new limits. Over the new limit, requests will require prior authorization for dates of service on or after August 1, 2021.

 

 

HCPCS Code Description Old Limit New Limit
A4233 Replacement battery, alkaline (other than j cell), for use with medically necessary home blood glucose monitor 1 per 6 months 1 per 12 months
A4236 Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor 1 per 6 months 1 per 12 months
A4250 Urine test or reagent strips or tablets (100 tablets or strips) 1 per 6 months 1 per 12 months
A4253 Blood glucose test or reagent strips for home blood glucose monitor 50 strips – 2 per month 2 boxes per year  – 100 strips per year
A4256 Normal, low and high calibrator solution / chips or just “Calibrator solution/chips Twice within 2 years No change
A4258 Spring-powered device for lancet, each or just “Lancet device each” Twice within 2 years No change
A4259 Lancets, per box of 100 or just “Lancets per box” One box per month 1 box per year, 100 Lancets per year
A9275 Home glucose disposable monitor 2  within 1 month 1 box per year

Next steps for providers: Providers should share this communication with their staff. Providers should submit DME supply requests for members with CGM through the medical benefit, and educate members about contacting TCHP for emergent situations.


If you have any questions, please email Provider Network Management at:
providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.

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