Read MEDICAID GUIDELINE text version

MEDICAID GUIDELINE Effective: 5-1-02

CONTINUOUS GLUCOSE MONITORING SYSTEM CPT CODE:

95250 Glucose monitoring for up to 72 hours by continuous recording and storage of glucose values from interstitial tissue fluid via a subcutaneous sensor (includes hook-up, calibration, patient initiation and training, recording, disconnection, downloading with print out of data)

CRITERIA FOR REIMBURSEMENT:

· · · · · · Have glycohemoglobin (HbgA1C) values <4 or >9 despite treatment Have unexplained large fluctuations in daily preprandial glucose values Have unexplained frequent hypoglycemic attacks Have episodes of ketacidosis or hospitalizations for glucose out of control Have diabetes and newly pregnant or about to conceive Initiation of an insulin pump regimen

Initiating insulin would not be an indication for CGMS unless one of the above criteria is met. To report physician review, interpretation and written report associated with code 95250, see Evaluation and Management services codes. An endocrinologist must consult and/or order the CGMS device to show medical necessity. Frequency: allowable 3 times per year for patients meeting the above criteria.

Pre-authorization needs to be done before services are rendered.

SP/ 4-19-01

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MEDICAID GUIDELINE

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