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Medical Policy: 09.01.01
Original Effective Date: February 1989
Reviewed: November 2011
Revised: July 2009
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Diabetes is a chronic illness that requires continuing medical care and education in order to prevent acute complications and reduce the risks of developing other conditions related to uncontrolled blood glucose. These other conditions may include retinopathy, nephropathy, neuropathy, and cardiovascular disease.
Outpatient diabetes training is a program that educates patients in the successful self-management of diabetes. The program includes education about self-monitoring of blood glucose and diet and exercise, as well as an insulin treatment plan for those who are insulin dependent. Diabetes education programs provided in Iowa must, according to State law, be certified by the Iowa Department of Public Health.
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Prior Approval:
Not applicable
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Policy:
When diagnosed with any type of diabetes and prescribed by a physician, the following services are considered medically necessary:
- Blood glucose meter and glucose strips for self-monitoring at home.
- Outpatient diabetes self-management training or education program certified by the Iowa Department of Health:
- At least 10 hours of initial training provided within a continuous 12 month period; and
- Up to 2 hours of follow up diabetes self-management training or education annually each subsequent year for those who have completed the initial training.
Diabetes outpatient self-management training is not a covered benefit if the above criteria are not met.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- Providers may use the following HCPCS codes to report diabetes outpatient education and training:
- G0108 Diabetes outpatient self management training services, individual session/30 minutes
- G0109 Diabetes outpatient self management training services, group sessions/30 minutes
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Selected References:
- Iowa Code 2003: Section 514C.18 Diabetes Coverage.
- American Diabetes Association (2003) Third party reimbursement for diabetes care, self-management education, and supplies. Diabetes Care, 26(1),S143-S144.
- American Diabetes Association. Third-Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies. Diabetes Care January 2009 32:S85-S86.
- Iowa Code 2009: Section 514C.18 Diabetes Coverage
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Policy History:
Date Reason Action
October 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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