E09.3519 — Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- CGM devices billed as HCPCS E2103 (and E2102 effective July 1, 2022) must have PDAC coding verification and be listed on the PDAC Product Classification List (PCL) for the respective HCPCS code prior to billing.
- For items subject to Final Rule 1713, a face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for specified HCPCS codes; claims without these will be denied as not reasonable and necessary and items delivered prior to receipt of a WOPD are ineligible for payment.
- If beneficiary utilization of BGM testing supplies exceeds usual amounts, the medical record must document an in-person or Medicare-approved telehealth visit evaluating diabetes control, that ordered quantities are reasonable and necessary, and that beneficiary testing frequency corroborates dispensed quantities (narrative or testing log).
Key Coverage Criteria
- Medicare may classify adjunctive CGMs as DME (since Feb 28, 2022) when LCD and statutory requirements are met.
- Home blood glucose monitors (BGMs) and continuous glucose monitors (CGMs) are covered under the Durable Medical Equipment (DME) benefit when the device and use meet the related LCD reasonable-and-necessary requirements and other Medicare statutory/regulatory requirements.
- Therapeutic (non-adjunctive) CGM devices that permit treatment decisions without confirmatory BGM are covered under DME.
- A CGM system supply allowance (HCPCS A4238 or A4239) is covered when the beneficiary uses a stand-alone durable CGM receiver or an insulin infusion pump classified as DME to display glucose data, or when a non-DME device is used in conjunction with a durable CGM receiver.
- For non-adjunctive CGM systems, the supply allowance (A4239) may include a home BGM and related supplies if clinically necessary.
- Beneficiary has diabetes mellitus documented in the medical record.
11 Active Policies
A56232 — Billing and Coding: Foot Care
J05
A57637 — Billing and Coding: Visual Field Examination
J09
L33766 — Visual Field Examination
J09
A52501 — Therapeutic Shoes for Persons with Diabetes - Policy Article
J19
A52507 — External Infusion Pumps - Policy Article
Related Codes
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