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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

January 2020

Medicare Advantage: Diabetes Updates for March 1


Harvard Pilgrim is updating our StrideSM (HMO) Medicare Advantage Diabetes Management Devices Medical Policy, effective for dates of service beginning March 1, 2020.

Updates are being made to coverage criteria for continuous glucose monitoring systems, insulin pumps, and sensor-augmented pump therapy, as well as for the replacement of diabetes management devices and for enhancements and accommodations for the visually and/or auditorily impaired.

Additionally, the following CPT and HCPCS codes will be added to the policy and will require prior authorization:

  • 95250 – Ambulatory continuous glucose monitoring of interstitial
  • 95249 – Patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training and printout of recording
  • A9274 – External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories
  • E0784 – External ambulatory infusion pump, insulin [when specified as an open-loop automated insulin
  • K0553 – Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 Unit of Service
  • K0554 – Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system

The policy will also be updated to reflect that the Eversense Continuous Glucose Monitoring System and Omnipod Dash insulin pump are considered experimental/investigational and are not eligible for reimbursement.

To request authorization, please complete the Durable Medical Equipment (DME) Medicare Advantage Prior Authorization Request Form and fax it to 866-874-0857 or call the Medicare Advantage Provider Service Center at 888-609-0692. For more information, please refer to the updated StrideSM (HMO) Medicare Advantage Diabetes Management Devices Medical Policy.

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