Medical Policy: 09.01.02
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 risk of developing other conditions related to uncontrolled blood glucose. These other conditions 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 South Dakota, according to State law, must be provided by a physician, nurse, dietician, pharmacist, or other licensed health care provider who satisfies the current academic eligibility requirements of the National Certification Board for Diabetic Educators and has completed a course in diabetes education and training or has been certified as a diabetes educator; and the training and education is based upon a diabetes program recognized by the American Diabetes Association or a diabetes program with a curriculum approved by the American Diabetes Association (ADA) or the South Dakota Department of Health.
Outpatient diabetes self-management training and education services are considered medically necessary for members who meet one of the following criteria, as defined by the South Dakota State Code:
An outpatient diabetes self-management training and education program provided in South Dakota is limited to the following:
Coverage is limited to the closest available qualified education program that provides the necessary management training to accomplish the prescribed treatment.
Diabetes self-management training is considered not medically necessary if the above criteria are not met.
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.
*CPT® is a registered trademark of the American Medical Association.