|Highmark Commercial Medical Policy - Pennsylvania|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Effective February 12, 1999 as defined by Pennsylvania Act 98 - 1998 Diabetes Supplies and Education Mandate diabetic services and education orthotics equipment and supplies are eligible for patients with insulin or noninsulin dependent diabetes insulin or noninsulin using diabetes or gestational diabetes. These services and supplies must be prescribed by a health care professional legally authorized to prescribe such items. Therefore requests for these services and supplies must include a physician prescription including necessary information for the service or supply being requested,
Coverage for the services as defined by Pennsylvania Act 98 - 1998 for diabetic services and supplies are subject to annual deductibles and coinsurances and all other terms and conditions set forth in the patient's contract.
Diabetic Equipment and Supplies
The following diabetic equipment and supplies designed for individual use are eligible for coverage when prescribed by a physician:
Diabetic equipment and supplies are covered when the glucose monitor is covered.
Quantity Level Limits (QLL) for test strips, lancets lens shield cartridge
The quantity of test strips, lancets and replacement lens shield cartridges that are covered depends on the medical needs of the diabetic individual according to the following guidelines:
Less than or equal to 12 years old and under:
Greater than or equal to 13 years old:
When ALL of the following criteria are met:
*Glucose test strips - one (1) unit of service = one (1) box (50-51 strips).
**Lancets- one (1) unit of service = one (1) box (100 lancets).
Testing supplies are considered not medically necessary if all of the above criteria are not met.
All Diabetic Patients
More than one (1) spring powered device is considered not medically necessary.
QLLs Exceeded for test strips lancets lens shield cartridge
QLLs that exceed the allowed amount of strips, lancet, and lens shield cartridges are covered when ALL of the following are met.
QLLs of test strips, lancets, or lens shield cartridges are considered not medically necessary if they exceed the frequency guidelines in this policy and the above criteria are not met.
I-Port Injection Port (Patton Medical Devices)
I-Port Injection Port (Patton Medical Devices) is considered experimental/investigational and, therefore, non-covered. There is a lack of scientific-based evidence of long-term studies demonstrating the safety and efficacy of this device.
Diabetes Outpatient Self-Management and Training Service may be considered medically necessary for the diabetic individual when prescribed by a licensed physician in ANY of the following circumstances:
All other circumstances are considered not medically necessary.
Medical Nutrition Therapy (MNT) is covered and will be processed in accordance with the information on Medical Policy V-44.
Diabetic shoes and the Lang Medical Shoe foot pressure off-loading/supportive devices inserts and/or modifications to those shoes are eligible when BOTH of the following criteria are met:
All other indications are considered not medically necessary.
QLLs for diabetic shoes and inserts
Individuals meeting the above orthotic coverage is limited to ONE (1) of the following within one (1) calendar year:
Note: A modification of a custom-molded or depth shoe will be covered as a substitute for an insert.
Diabetic shoes and custom inserts will be denied as not medically necessary if the above criteria are not met.
Deluxe Shoe Feature is non-covered because it does not contribute to the therapeutic function of the shoe. Features may include but are not limited to style color or type of leather.
See medical policy V-44 Medical Nutrition Management Services (MNT) for additional information.
See medical policy Z-27 Eligible Providers and Supervision Guidelines for additional information.
Diabetic services and supplies is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider cannot bill the member for the non-covered service.
07/2015, Quantity Level Limits for Diabetic Test Strips and Lancets are Increased
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.