Medical Policy: 09.01.01
Original Effective Date: February 1989
Reviewed: May 2016
Revised: June 2015
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.
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 education and self-management training is a formalized, comprehensive outpatient program that teaches individuals who have been diagnosed with diabetes about their diagnosis and its treatment. Components of such programs typically include, but are not limited to the following: blood glucose self-monitoring; dietary requirements; exercise and its role in the management of diabetes; if necessary, instruction on the self-administration of pharmaceutical agents for the treatment of diabetes, as well as an insulin treatment plan.
Diabetes education programs provided in Iowa, according to State law, must be certified by the Iowa Department of Public Health.
When diagnosed with any type of diabetes and prescribed by a physician, the following services are considered medically necessary:
- Blood glucose meter and supplies 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 considered not medically necessary if the above criteria are not met.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis 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
S9140 Diabetic management program, follow up visit to non-MD provider
S9141 Diabetic management program, follow up visit to MD provider
S9455 Diabetic management program, group session
S9460 Diabetic management program, nurse visit
S9465 Diabetic management program, dietician visit
- 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
- Iowa Department of Public Health: Iowa Diabetes Prevention & Control ProgramExternal Site
- Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management educationExternal Site. Diabetes Care(serial online). 2009;32:S87-S94. [Diabetes Care Web site].
May 2016 - Annual Review, Policy Renewed
June 2015 - Annual Review, Policy Revised
July 2014 - Annual Review, Policy Renewed
September 2013 - Annual Review, Policy Renewed
October 2012 - Annual Review, Policy Renewed
Novemeber 2011 - Annual Review, Policy Renewed
October 2010 - Annual Review, Policy Renewed
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 © 2012 American Medical Association. All Rights Reserved.