Darryl
10-06-2008, 09:33 PM
Independence Blue Cross of PA just issued a revision to its medical policy 5.00.24d for
Continuous Glucose Monitors. The new revision 5.00.24e now considers CGM's "medically
necessary and therefore approved" for Type 1 diabetic patients who meet 5 seemingly
reasonable criteria.
This new policy refers to "real-time CGMS application in diabetic care." The old policy
stated that the CGM was simply an "adjunct to fingerstick testing and therefore not
medically necessary". It seems like IBC finally gets the point...
Assuming that IBC follows through and actually honors this new policy, I consider this to
be a major victory for CGMS coverage, from a major Blue Cross organization.
The only sticking point I see in obtaining coverage is the requirement for "severe ketosis
or hypoglycemic episodes". Document your BG's well if seeking coverage!
I also want to point out that this study referenced the recent JDRF article that was published
in the New England Journal of Medicine - the article that appeared to conclude that CGM's
were not effective in children due to non-compliance and/or lack of training. It seems that
the policy commitee addressed this issue by requiring certification that the patient was
skilled in self-management, and that the patient received training from a medical professional
in CGMS use.
Following is an exerpt from the new policy. Anyone with IBC coverage may want to revisit
their prior claims.
Title: Invasive Continuous Glucose Monitoring Systems
Policy#: 05.00.24e
LONG-TERM INVASIVE CGMS
Use of a long-term invasive CGMS to measure interstitial glucose levels via a subcutaneously implanted sensor is considered medically necessary and, therefore, covered when an individual demonstrates one of the following criteria:
The individual is a pregnant female with type I diabetes, or:
The individual has type I diabetes and documentation of all of the following:
The CGMS is prescribed by an endocrinologist.
The individual is on an intensive insulin regimen, requiring two or more insulin injections per day, or utilizes an insulin pump
The individual has a documented history of severe ketosis or hypoglycemic episodes without experiencing warning and recognition of symptoms (hypoglycemic unawareness).
The individual has demonstrated mastery of the fundamentals of diabetes self-management, which includes:
Routine, regular testing of blood glucose levels at least three times a day
Maintaining accurate records of blood glucose testing
The individual has received education and training from anaccredited health care professional to master the CGMS, including all of the following:
Basic care of the device (eg, insertion, calibration, expectations)
Use of real-time CGMS application in diabetic care
Alarm use and problem solving
Continuous Glucose Monitors. The new revision 5.00.24e now considers CGM's "medically
necessary and therefore approved" for Type 1 diabetic patients who meet 5 seemingly
reasonable criteria.
This new policy refers to "real-time CGMS application in diabetic care." The old policy
stated that the CGM was simply an "adjunct to fingerstick testing and therefore not
medically necessary". It seems like IBC finally gets the point...
Assuming that IBC follows through and actually honors this new policy, I consider this to
be a major victory for CGMS coverage, from a major Blue Cross organization.
The only sticking point I see in obtaining coverage is the requirement for "severe ketosis
or hypoglycemic episodes". Document your BG's well if seeking coverage!
I also want to point out that this study referenced the recent JDRF article that was published
in the New England Journal of Medicine - the article that appeared to conclude that CGM's
were not effective in children due to non-compliance and/or lack of training. It seems that
the policy commitee addressed this issue by requiring certification that the patient was
skilled in self-management, and that the patient received training from a medical professional
in CGMS use.
Following is an exerpt from the new policy. Anyone with IBC coverage may want to revisit
their prior claims.
Title: Invasive Continuous Glucose Monitoring Systems
Policy#: 05.00.24e
LONG-TERM INVASIVE CGMS
Use of a long-term invasive CGMS to measure interstitial glucose levels via a subcutaneously implanted sensor is considered medically necessary and, therefore, covered when an individual demonstrates one of the following criteria:
The individual is a pregnant female with type I diabetes, or:
The individual has type I diabetes and documentation of all of the following:
The CGMS is prescribed by an endocrinologist.
The individual is on an intensive insulin regimen, requiring two or more insulin injections per day, or utilizes an insulin pump
The individual has a documented history of severe ketosis or hypoglycemic episodes without experiencing warning and recognition of symptoms (hypoglycemic unawareness).
The individual has demonstrated mastery of the fundamentals of diabetes self-management, which includes:
Routine, regular testing of blood glucose levels at least three times a day
Maintaining accurate records of blood glucose testing
The individual has received education and training from anaccredited health care professional to master the CGMS, including all of the following:
Basic care of the device (eg, insertion, calibration, expectations)
Use of real-time CGMS application in diabetic care
Alarm use and problem solving