Original Issue Date (Created): July 1, 2005 Most Recent Review Date (Revised): Effective Date: May 24, 2011 August 31, 2011- RETIRED I. POLICY Initial diabetic self-management training (DSMT) may be considered medically necessary when ordered by a physician managing the patient s diabetic condition. Diabetic self-management training (DSMT) may be provided as either group training (series) or individual (1:1) sessions. The DSMT program must be a standard program recognized by the American Diabetes Association (ADA) or the American Association of Diabetes Educators (AADE). DSMT may be considered medically necessary for patients with the following conditions: A change in treatment regimen from diet control to oral diabetes medication, or from oral diabetes medication to insulin Gestational diabetes Inadequate glycemic control as evidenced by a glycosylated hemoglobin (HBA1c) level of 7% or more Metabolic syndrome New onset diabetes Pre-diabetes High risk for complications based on at least one of the following: 1. Frequent episodes of hypo and/or hyperglycemia 2. Kidney complications related to diabetes 3. Lack of feeling in the foot, other foot complications such as ulcers, deformities, or amputation 4. LDL greater than 100 mg/dl 5. Pre-proliferative or proliferative retinopathy or prior laser treatment of the eye 6. Sustained blood pressure greater than 130/80. Follow-up diabetic self-management training may be considered medically necessary for patients with the following conditions: Any of the above Initiation of an insulin pump Page 1
When a new medication or therapeutic process relating to treatment and/or management of diabetes is identified as medically necessary by a licensed physician Changes in self-management are necessary due to a change in condition, symptoms, and/or complications. Cross-references MP-6.026 Durable Medical Equipment (refer to Blood Glucose Monitors) MP-6.007 External Infusion Pumps II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] Capital Cares 4 Kids [N] PPO [N] HMO [N] FEP PPO [Y] SeniorBlue PPO* [N] Indemnity [N] SpecialCare [N] POS [Y] SeniorBlue HMO* * Refer to Medicare Benefit Policy Manual. Publication 100-02. Chapter 15, Section 300, 300.3, 300.4, 300.5. Will cover two (2) hours of follow-up training each year starting with the calendar year following the year in which the member completes the initial training. The two (2) hours training may be given in any combination of half-hour increments within each calendar year on either an individual or group basis. * Refer to Centers for Medicare and Medicaid (CMS) National Coverage Determination (NCD) 180.1, Medical Nutrition Therapy. The medical nutrition therapy (MNT) benefit is a completely separate benefit from the DSMT benefit. However, members are not allowed to receive DSMT and MNT on the same date of service. In subsequent years the beneficiary can receive two (2) hours of DSMT and two (2) hours of MNT. Page 2
III. DESCRIPTION/BACKGROUND Diabetic self-management training (DSMT) is the process of providing an individual with diabetes and related conditions the education and skills to perform self-care on a day-to-day basis. Self-management education teaches an individual to assess the relationships among medical nutrition therapy, activity level, emotional and physical status, and medications, and then respond appropriately and continually to those factors to achieve and maintain optimal glucose control. In addition to optimizing metabolic control, the goals of diabetes education are to prevent acute and chronic complications and achieve optimal quality of life. Pennsylvania State Mandate Act 98 of 1998 requires coverage of outpatient selfmanagement training and education (including medical nutrition therapy) for the treatment of insulin-dependent diabetes and non-insulin using diabetes. Coverage is also required when a new medication or therapeutic process relating to the person s treatment and/or management of diabetes has been identified as medically necessary by a licensed physician. Diabetic self-management training is an interactive, collaborative process involving individuals, their physician, and instructors. The American Diabetes Association (ADA) has developed a set of National Standards for Diabetes Self-Management Education. DSMT programs must meet national standards in order to be recognized by the ADA. A DSMT instructional team is typically multidisciplinary in nature, but must consist of at least a registered dietitian and a registered nurse. The American Diabetes Association recognizes that DSMT programs may be provided in a variety of healthcare settings, including physicians' offices, clinics, and hospitals. IV. DEFINITIONS ACT 98 OF 1998 refers to a Pennsylvania state mandate that requires coverage of equipment, supplies, and outpatient self-management training and education (including medical nutrition therapy) for the treatment of insulin-dependent diabetes and non-insulin using diabetes. Equipment and supplies include blood glucose monitors, monitor supplies, insulin, injection aides, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar, and orthotics. Page 3
V. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VI. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VII. REFERENCES American Diabetes Association: National Standards for Diabetes Self- Management Education (Standards and Review Criteria). Diabetes Care 31):S97 S104, 2008. January 2008. [Website]:. http://care.diabetesjournals.org/search?fulltext=national+standards+for+diabet es+self- Management+Education+%28Standards+and+Review+Criteria&submit=yes&x =0&y=0 Accessed February 11, 2011. American Diabetes Association: Standards of Medical Care in Diabetes-2008. Diabetes Care 31: S97-S104, 2008. [Website]: http://care.diabetesjournals.org/cgi/content/full/31/supplement_1/s12. Accessed February 11, 2011. Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Publication 100-02. Chapter 15, Section 300, 300.3, 300.4, 300.5. Effective 7/01/07. [Website]: http://www.cms.gov/manuals/iom/itemdetail.asp?filtertype=none&filterbydid=- 99&sortByDID=1&sortOrder=ascending&itemID=CMS012673&intNumPerPage =10Accessed February 11, 2011. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 180.1. Medical Nutrition Therapy. Effective 10/03/03. CMS [Website]: http://www.cms.gov/medicare-coverage-database/details/ncd- Page 4
details.aspx?ncdid=252&ncdver=1&docid=180.1&bc=gaaaabaaaaaa& Accessed February 11, 2011... Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 40.1. Diabetes Outpatient Self-management Training. Effective 06/19/06. CMS [Website]: http://www.cms.gov/medicare-coveragedatabase/details/ncddetails.aspx?ncdid=251&ncdver=1&docid=40.1&bc=gaaaabaaaaaa& Accessed February 10, 2011. Code of Federal Regulations (CFR). Title 42: Public Health. Subpart H Outpatient Diabetes Self-Management Training and Diabetes Outcome Measurements. Section 410.140-410.146 Current as of 02/09/11. [Website]: http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=acb5dc1a3948e45a32830ec01cdb3ac7&rgn=div5&view=text&n ode=42:2.0.1.2.10&idno=42#42:2.0.1.2.10.8 Accessed February 10, 2011. ECRI Custom Hotline Report. Efficacy of Prevention Programs for Type II Diabetes. Updated 10/15/2008. Pennsylvania State Mandate Act 98 of 1998 (Reimbursement of Diabetic Supplies Act). VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes 97802 97803 97804 Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. HCPCS Code G0108 G0109 Description DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, INDIVIDUAL, PER 30 MINUTES DIABETES SELF-MANAGEMENT TRAINING SERVICES, GROUP SESSION (2 OR MORE), PER 30 MINUTES Page 5
G0270 G0271 S9452 S9470 MED NUT TX; REASSESS FLW 2 REF YR W/PT EA 15 MIN MED NUT TX REASSESS FLW 2 REF YR GRP EA 30 MIN NUTRITION CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION NUTRITIONAL COUNSELING, DIETITIAN VISIT ICD-9-CM Code* Description 249.00-249.91 SECONDARY DIABETES MELLITUS 250.00-250.93 DIABETES MELLITUS *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. The following ICD-10 diagnosis codes will be effective October 1, 2013 ICD-10-CM Diagnosis Code* Description *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. Page 6
IX. POLICY HISTORY MP 2.076 CAC 4/26/05 CAC 4/25/06 CAC 3/27/07 CAC 3/25/08 CAC 1/27/09 Consensus CAC 1/26/10 Consensus Review. No change in policy statement. References updated. CAC 4/26/11 Consensus review. Policy approved for retirement 8/31/2011. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 7