Provider Alert! Diabetic Equipment and Supplies Benefits to Change for Texas Medicaid

Date: December 17, 2021

Attention: Endocrinologists and Primary Care Providers

Effective Date: September 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: New information updated December 17, 2021 with an effective date of September 1, 2021, Diabetic equipment and supplies procedure code A9276 sensor for use with CGM will be limited to 30 services allowed per 30 days (one unit equals a one-day supply), same procedure, any provider.
Effective for dates of service on or after September 1, 2021, diabetic equipment and supplies benefits will change for Texas Medicaid.

Major changes to this medical benefit include the following:

• Adding new benefit for adjunct continuous glucose monitoring (CGM) system
• Adding new benefit for CGM integrated insulin pump system
• Expanding the Omnipod benefit to adult diabetic population

Adjunct CGM System

CGMs are devices that measure glucose levels taken from interstitial fluid continually throughout the day and night, providing real-time data to the client or physician. The CGM has three parts:

• A disposable sensor, which attaches to the skin and inserts a tiny wire into the subcutaneous tissue to measure glucose levels
• A transmitter, which attaches to the sensor and sends the data to a wireless receiver/monitor
• A receiver/monitor, which records and stores the data and alerts the client when glucose levels are too high or too low

Disposable sensor procedure code A9276, external transmitter procedure code A9277, and receiver/monitor procedure code A9278 will be benefits when provided by medical supplier durable medical equipment (DME) providers in the home setting.

How this impacts provider: Procedure codes A9276, A9277, and A9278 will require prior authorization and will be limited as follows:

• Prior authorization is required for a long-term personal CGM system for clients with diabetes to use at home.
• The CGM system may be one of the following:
• Therapeutic CGM system (as defined by the Centers for Medicare & Medicaid Services), which includes the supplies (procedure code K0553) and device (procedure code K0554), and replaces the use of a standard home blood glucose monitor (SBGM)
• Adjunct CGM system, which includes the sensor (procedure code A9276), transmitter (procedure code A9277), and receiver/monitor (procedure code A9278), and supplements the use of an SBGM

Next steps for providers: Providers should share this communication with their staff.

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.