Proposed diabetes changes leave sour taste

Thursday, October 28, 2010

BALTIMORE - When it comes to diabetes treatment, one size doesn't fit all, stakeholders told CMS medical directors at an Oct. 26 public hearing on the proposed changes to the benefit.

The changes, outlined in a draft local coverage determination (LCD) issued in September, would limit the number of allowed strips, based on frequency of injections, to six per day for insulin-dependent beneficiaries. It would limit the number of allowed strips to one per day for non-insulin dependent beneficiaries.

"It's not that cookie cutter," said Chris Smith, director of policy and regulatory affairs for the National Community Pharmacists Association. "Every individual has different variables that may require them to test more frequently on some days than others."

CMS will accept comments on the draft LCD until Nov. 8. Providers can e-mail comments to each jurisdiction's medical director.

The number of allowed strips in the draft LCD simply isn't enough for some patients, said Kathleen Belmonte, COO of Woburn, Mass.-based Neighborhood Diabetes, one of the largest mail order providers in the country.

"There's a large number of patients we serve that are testing above the (proposed) limits," said Belmonte. "By limiting and not allowing any overages, there could be some clinical implications."

If Medicare won't pay for additional strips, beneficiaries probably won't either, especially those on fixed incomes, Belmonte said.

"I honestly feel that many would choose to sacrifice their health (if they can't) test at what their healthcare provider recommends," she said.

The draft LCD also seeks to require additional documentation regarding physician-beneficiary contact and a testing log maintained by the beneficiary that demonstrates the prescribed frequency for 70% of the testing times.

"(DME providers) can't control what (physicians document) in the record, but without the proper documentation, you are going to have claims denied," said Smith.

And, if a physician thinks a patient should test more frequently than what the draft LCD proposes, it shouldn't be up to the HME provider to question that, said Belmonte.

"I am asking my employees to collect medical information from the (healthcare) provider and determine whether there is medical necessity," she said. "How realistic is it to have an ancillary supplier go back to the endocrinologist and question their care plan?"