Diabetes Management
DESCRIPTION
Diabetes is a chronic illness that requires continuing medical care and education to prevent complications related to uncontrolled blood glucose. Complications of diabetes may include retinopathy, nephropathy, neuropathy, and cardiovascular disease.
POLICY
Diabetes management is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
The medical appropriateness criteria below, except for the statement regarding Hemoglobin A1c, are based on a Tennessee State Mandate - Tennessee Code Annotated, Title 56, Chapter 7, Part 2605.
MEDICAL APPROPRIATENESS
Diabetes management is considered medically appropriate if ALL of the following are met:
Requested service is for the treatment or management of diabetes
Requested service is ordered by a physician
Requested service includes ANY ONE of the following:
Diabetic training/education/nutritional counseling when ANY ONE of the following are met:
Initial diagnosis of diabetes
There is a significant change in the individual's condition which necessitates changes in the individual's self-management
Re-education or refresher training is necessary
Hemoglobin A1c testing for Type I and Type II diabetics should be performed at intervals of no less than every 6 months
Equipment, medication and supplies to include ONE or more of the following:
Blood glucose monitors - including monitors for the legally blind
Test strips
Visual reading and urine test strips
Insulin
Injection aids
Syringes
Lancets
Insulin pumps, infusion devices, and medically necessary accessories
Podiatric appliances for prevention of complications associated with diabetes
Glucagon emergency kits
Oral hypoglycemic agents
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
Providers that will be recognized to provide the outpatient self-management diabetic training, educational services, and the nutritional counseling include:
Licensed physicians
Registered nurses or dietitians
Pharmacists who have completed a diabetic patient management program recognized by the American Council on Pharmaceutical Education and the Tennessee Board of Pharmacy
Other contracted or credentialed providers may be recognized as eligible providers following evaluation and approval by BlueCross BlueShield of Tennessee
SOURCES
American Diabetes Association. (2023, January). Retrieved February 13, 2024 from www.Diabetes.org/diabetescare.
Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 26 Mandated Insurer or Plan Options: 56-7-2605. Equipment, supplies and outpatient services for diabetic patients. Retrieved February 13, 2024 from https://web.lexisnexis.com.
ORIGINAL EFFECTIVE DATE: 7/1/1997
MOST RECENT REVIEW DATE: 3/14/2024
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.