Provider Talking Points for Reason Codes on Remittance Advice

Provider Claims FAQ

Provider Talking Points for Carve Out Benefits

What are the CGM coverage requirements under Medicare?

CGMs are covered for members who:

•   Have been diagnosed with diabetes mellitus; AND

•   Have had a visit within the last six (6) months with his or her prescriber;AND

•   Meets at least one of the following criteria;

    ◦   Member is being treated with insulin; OR

    ◦   Member has a history of problematic hypoglycemia with documentation of at least one of the following:

        ▪   Recurrent (more than one) level 2 hypoglycemic events (glucose < 54mg/dL) that persists despite multiple (more than 1) attempts to adjust medications and/or the diabetes treatment plan; OR

        ▪   History of one level 3 hypoglycemic event (glucose < 54 mg/dL) characterized by altered mental and/or physical state requiring third-party assistance.

All coverage requests should be submitted through the member’s medical group.  For Medicare coverage policies, please see Local Coverage Determination (LCD): Glucose Monitors (L33822) and Local Coverage Article: Glucose Monitor - Policy Article (A52464).

What are the differences between non-adjunctive vs. adjunctive CGMs?

Non-adjunctive CGMs can be used as a complete replacement for traditional fingerstick blood glucose testing supplies and do not require a separate blood glucose monitor (BGM) to confirm testing results.

Adjunctive CGMs must be used in conjunction with standard finger stick tests using a home BGM to confirm testing results.

Both non-adjunctive and adjunctive CGMs are considered DME.

Why is my patient’s CGM rejecting/not covered at the pharmacy?

CGM supplies are covered under the durable medical equipment (DME) benefit under Medicare. For SCAN members, DME supplies are provided by the medical group’s contracted DME supplier and are not coverable under the pharmacy benefit.

My patient previously received a fill at the pharmacy, why is their CGM refill now rejecting?

Your patient may have received a temporary fill during their first 90 days of enrollment with SCAN at the pharmacy. Known as a transition fill, this allows patients to have access to these CGM supplies while they are new to the plan. This transition fill also allows you time to request authorization (referral) from the medical group to cover and supply CGMs under the DME benefit.

Why are CGMs covered under the DME benefit and not the pharmacy benefit (Part D)?

Medicare covers CGMs under the DME benefit. For SCAN members, this benefit is managed by the medical group and will not be covered at the pharmacy. Please make sure you DO NOT send an authorization request to Express Scripts. They only manage pharmacy authorizations and will not process your request.

What are the next steps to ensure my patient receives their CGMs in a timely manner?

Submit an authorization to your patient’s medical group with the appropriate CGM DME supply codes to ensure the CGM gets covered. 

CGM Type	HCPCS Code	Description		Common Examples
Non-Adjunctive	E2103	Receiver (monitor), dedicated, for use with non-adjunctive glucose continuous monitor system		Freestyle Libre 14 Day System FreeStyle Libre 2 Reader Dexcom G5 Receiver Dexcom G6 Receiver
	A4239	Supply allowance for non-adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 Unit of Service		FreeStyle Libre 2 Sensors FreeStyle Libre 14 Day Dexcom G5 Sensors Dexcom G5 Transmitters Dexcom G6 Sensors Dexcom G6 Transmitters
Adjunctive	E2102	Adjunctive continuous glucose monitor or receiver		Minimed 630G System Minimed 670G System Minimed 770G System
	A4238	Supply allowance for adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service		Guardian Sensor 3 Guardian Sensor 3 Kit Guardian Transmitter 3 Guardian Transmitter 3 Kit Enlite Sensor Enlite Sensor Kit
Commonly Used ICD-10 Diagnosis Codes (for full list refer to LCA A52464)
E10.9			Type 1 diabetes mellitus without complications
E11.65			Type 2 diabetes mellitus with hyperglycemia
E10.65			Type 1 diabetes mellitus with hyperglycemia
E11.8			Type 2 diabetes mellitus with unspecified complications
E11.9			Type 2 diabetes mellitus without complications

1. Documentation showing that your patient meets the criteria to use CGM supplies.
2. Prescription for CGM supplies (refer to HCPCS and ICD-10 codes listed above).
3. Documentation showing that your patient’s diabetes diagnosis will be re-evaluated and managed every 6 months.

During the COVID-19 Public Health Emergency, Medi-Cal coverage was renewed automatically for Medi-Cal beneficiaries, even if they had changes in their household. Effective April 1, 2023 Medi-Cal beneficiaries need to renew their annual coverage in order to keep their health care benefits.

• Please ensure your patients update their contact information with their local county Medi-Cal office.
• Encourage patients to complete their Medi-Cal paperwork by the due date.
• Medi-Cal does not require a payment in the application or renewal process.
• California Medi-Cal Redetermination Provider Tool Kit

Medi-Cal Redetermination and the toolkit are applicable to SCAN dual eligible members enrolled in Connections and Connections at Home.