Effective Sept. 1, 2021: Diabetic Equipment and Supplies Benefits Changes – Texas Medicaid
What is New?
Beginning Sept. 1, 2021, there are major changes to the diabetic equipment and supplies benefits 
including the following:
- Adding new benefit for adjunct continuous glucose monitoring (CGM) system
- Adding new benefit for CGM integrated insulin pump system
- Expanding the Omnipod benefit to adult diabetic population
Adjunct CGM System:
The following procedure codes and limitations will be benefits when provided by medical supplier durable medical equipment (DME) providers in the home setting.
| Procedure Code | Limitation | Description |
|---|---|---|
| A9276 | Up to 5 per month | Disposable sensor |
| A9277 | 1 per 3 months | External Transmitter |
| A9278 | 1 per 3 years | Receiver/Monitor |
| A4253* | Reduced to two boxes | Test Strips |
| A4259* | One box | Lancets |
* If an adjunct CGM system is approved, the allowance for SBGM supplies submitted in addition to the approved adjunct CGM system will be reduced to two boxes of test strips (procedure code A4253) and one box of lancets (procedure code A4259) during the same calendar year by any provider.
CGM System:
Only one type of CGM system, either the therapeutic CGM system or adjunct CGM system, may be approved for qualified diabetic clients.
Therapeutic CGM System (as defined by CMS)
| Procedure Code | Description |
|---|---|
| K0553 | Supplies |
| K0554 | Device |
| These codes replace the use of a standard home blood glucose monitor (SBGM) | |
The ordering provider is responsible for requesting the appropriate device and supplies according to the client’s medical need and verifying that the client's condition meets the manufacturers' recommendations for appropriate age range, testing and calibration requirements, prior to prescribing the CGM device.
CGM Integrated Insulin Pump System:
Claims submitted for CGM integrated pump system must use procedure codes and modifiers below:
| Procedure Code | Modifier |
|---|---|
| E0784 | UD |
| A9276 | U4 |
| A9277 | U4 |
| A9278 | U4 |
Note:
Some CGM integrated pump systems use smart devices to monitor the system instead of a CGM receiver/monitor. The device provider is responsible for supplying the software applications to make the system work appropriately.
Omnipod
A tubeless external insulin pump (Omnipod) will be a benefit for clients of all ages as an alternative to the CGM integrated pump system.
| Procedure Code | Modifier/Description |
|---|---|
| E0784 | U1 |
| A9274 | Disposable pods, supplies, and accessories |
Claims submitted for Omnipod must use procedure codes and modifier below:
Have questions:
Contact our BCBSTX Medicaid Provider Service Center at 1-877-560-8055 or contact your BCBSTX Medicaid Provider Network Representative at 1-855-212-1615.
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.
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