Ask the DMERC MDs

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Wednesday, May 31, 2006

The DME PSC medical directors have received multiple requests for clarification on the July 1, 2005, LCD update for glucose monitors. Suppliers have specifically requested information on several points.
Q. Please clarify the July 1, 2005, glucose monitors LCD revision eliminating the requirement that a supplier obtain a renewal order from the treating physician every 12 months for those Medicare beneficiaries whose utilization does not exceed the indications and limitations stated in the LCD.
A. Glucose testing in diabetics is anticipated to be needed throughout their lifetime. Diabetics with glucose testing needs that fall within the utilization guidelines, as stated in the glucose monitors LCD, meet the indications and limitations of coverage. Unless there is a change in diabetic status that increases the need for glucose testing, it is anticipated that there will not be a significant change in utilization. It is therefore considered unnecessary for the Medicare beneficiary with diabetes to obtain a routine renewal order from the treating physician every 12 months
Q. For what dates of service does this apply?
A. This revision applies to dates of service on or after July 1, 2005. Dates of service prior to July 1, 2005, remain under the guidelines of the prior glucose monitors LCD, which requires a renewal order from the treating physician every 12 months.
Q. Please explain the continuation of the requirement that a diabetic Medicare beneficiary needing diabetic supplies exceeding the utilization guidelines of indication and limitations be examined every six months.
A. Medicare beneficiaries with diabetes needing quantities of diabetic supplies exceeding the utilization guidelines have an increased need for closer and more frequent medical management and physician supervision. Diabetics who have glucose testing needs that exceed utilization guidelines are therefore expected and required to undergo a physician evaluation every six months at a minimum. This requirement was not removed nor changed in the revised glucose monitors LCD.
Q. What type of information in the medical record documentation is needed in order to substantiate that the utilization of diabetic supplies exceeding the utilization guidelines is reasonable and necessary?
A. The LCD lists three pieces of information that must be recorded to justify high utilization of glucose monitor supplies:
- Order. The treating physician has ordered a frequency of testing that exceeds the utilization guidelines and the specific reason(s) why additional materials are needed for that particular patient.
- Evaluation. The treating physician has seen the patient and has evaluated his or her diabetes control at least every six months and continues to state the need for the frequency of testing in the plan of care that requires the quantities of strips and lancets or lens shield cartridges that exceed the utilization guidelines.
- Testing. The documentation in the physician's records contains a narrative statement that adequately documents the frequency at which the patient is actually testing or a copy of the beneficiary's log.
Q. Is it necessary for the treating physician to provide a renewal order every six months for those diabetic Medicare beneficiaries who use diabetic supplies exceeding the utilization guidelines as stated in the glucose monitors LCD?
A. It is not necessary that a renewal order be obtained from the treating physician for those diabetic Medicare beneficiaries requiring diabetic supplies that exceed the utilization guidelines unless there has been a change in clinical status. Whenever diabetic management necessitates a change in testing requirements that affects utilization, a new order from the treating physician is required and the medical record needs to document such a change and the reason(s) why this change in diabetic management is needed.

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