Provider Alert! Continuous Glucose Monitors Regular Durable Medical Supplies Limits

Date: September 24, 2021

Attention: Endocrinologists, PCPs and DME Providers

Subject: Continuous Glucose Monitors Regular Durable Medical Supplies Limits

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 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.

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 inform  members that they can obtain supplies through retail pharmacy benefit 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.