Glucose Monitoring – Home - Non-OneTouch Brand Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 05|01|2024 POLICY LAST REVIEWED: 01|22|2025 OVERVIEW Medicare Advantage Plans have a limited benefit regarding the brand of home blood glucose monitors Medicare Advantage Plan members may obtain. The preferred brand is OneTouch. This policy documents that criteria must be met when a request is received for a brand outside of the limited benefit. Therefore, this policy is applicable to Medicare Advantage Plans only. NOTE: For Commercial Products, there is no benefit limitation regarding brands; all brands of home blood glucose monitors are covered. MEDICAL CRITERIA Medicare Advantage Plans Clinical guidelines for approval of non-OneTouch branded products are found on the Blue Cross & Blue Shield of Rhode Island’s (BCBSRI) Pharmacy Benefit Management Program’s website at covermymeds.com PRIOR AUTHORIZATION Medicare Advantage Plans Prior authorization is required. Contact the BCBSRI Pharmacy Benefit Management Vendor at 1-800-693-

6651. Requests can also be sent via fax to 855-212-8110 or at covermymeds.com POLICY STATEMENT Medicare Advantage Plans Blood glucose meters and test strips are covered and are limited to OneTouch branded products. The list below identifies the examples of covered OneTouch products: OneTouch Monitor OneTouch Verio® Flex Meter
      OneTouch Verio® Meter
      OneTouch Verio® IQ Meter
      OneTouch Ultra® 2 Meter
      OneTouch Ultra® Mini Meter
      OneTouch Verio® Reflect Meter OneTouch Test Strips – See quantity limits in Coding section below OneTouch Ultra® Test Strips - 25, 50 or 100 strip box
      OneTouch Verio® Test Strips - 25, 50 or 100 strip box Any blood glucose monitors other than OneTouch branded products (including test strips) is covered when the coverage criteria is met.
      Modifiers Per Centers for Medicare and Medicaid Services (CMS) guidelines, for blood glucose monitoring equipment and related supplies, the following modifiers must be added to the HCPCS supply code(s) on every claim submitted to ensure claim reimbursement: • Use modifier KX if the beneficiary is insulin treated; or, • Use modifier KS if the beneficiary is non-insulin treated. Medical Coverage Policy | Glucose Monitoring – Home - Non-OneTouch Brand

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

The KX modifier must not be used for a beneficiary who is not treated with insulin injections.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable durable medical equipment benefits/coverage.

BACKGROUND A blood glucose monitor (glucometer) is a portable, battery-operated device used to determine the blood glucose level by exposing a reagent strip to a small blood sample. The patient uses a disposable lancet, draws a drop of blood, places it on a reagent strip, and inserts it into the monitor, which provides the patient with a direct readout of the blood glucose level. Test results may also be stored in memory on the device for download or viewing at a later time. The test strips may be separate items that are inserted into the monitor or self-contained in a cylinder or disk-type mechanism.

Blood glucose monitors with integrated voice synthesizers are devices that measure capillary whole blood for determination of blood glucose levels. Results are displayed on a screen but are also digitized and converted to sound output.

Blood glucose monitors with integrated lancing and/or blood sampling are devices that measure capillary whole blood for determination of blood glucose levels. The lancing device for obtaining the capillary blood sample is integrated into the glucose monitor rather than a separate accessory.

Insulin-treated means that the member is receiving insulin injections to treat their diabetes. Insulin does not exist in an oral form and therefore members taking oral medication to treat their diabetes are not insulin treated.

CODING Modifiers Per Centers for Medicare and Medicaid Services (CMS) guidelines, for blood glucose monitoring equipment and related supplies, the following modifiers MUST BE added to the HCPCS supply code(s) on every claim submitted to ensure claim reimbursement: • Use modifier KX if the member is insulin treated; or, • Use modifier KS if the member is non-insulin treated. The KX modifier must not be used for a member who is not treated with insulin injections.

Diabetic Testing Supply Limits – Test Strips (A4253) and Lancets (A4259)

Medicare Advantage Products For items requested for a non-OneTouch branded product:

The following HCPCS codes are covered when the medical criteria above are met: Note: To ensure correct claims processing, claims must be filed with the HCPCS and NDC for the device dispensed. A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips A4259 Lancets, per box of 100* A4271 Integrated lancing and blood sample testing cartridges for home blood glucose monitor, per 50 tests (New Code Effective 4/1/2024; Text Revision Effective 10/1/2024) E0607 Home blood glucose monitor E2100 Blood glucose monitor with integrated voice synthesizer E2101 Blood glucose monitor with integrated lancing/blood sample Insulin Dependency Unit Limit Timeframe Insulin Dependent 500 3 months Non-Insulin Dependent 200 3 months

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

E2104 Home blood glucose monitor for use with integrated lancing/blood sample testing cartridge (New Code Effective 4/1/2024)

*Note: There is no benefit limitation regarding brands of lancets.

RELATED POLICIES Glucose Monitoring – Continuous

PUBLISHED Provider Update, March 2025 Provider Update, March 2024 Provider Update, April 2023 Provider Update, June 2022 Provider Update, April 2021

REFERENCES Not applicable

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS