Does A4210 require prior authorization?

No, A4210 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for A4210?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`A4210`, Needle-free injection device, each

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For diabetes self-care programs: a physician order from the treating physician and a statement signed by the physician that the service is needed.
For reflex/diagnostic anti-GAD antibody testing: documentation that the clinical history is ambiguous and that test results will influence patient management.

For jet injectors as DME: documentation that the member or the member's caregiver is physically unable to use a conventional needle-syringe (e.g., severe arthritis, severe tremors, blindness) and medical necessity justification.

For reflectance/voice-enabled meters and DME for the visually impaired: documentation of legal blindness (best corrected visual acuity less than 20/200).

For blood glucose monitors with integrated lancing/blood sample: documentation that patient meets either legal blindness criteria or has impairment of manual dexterity severe enough to require the device.

For alternate site blood glucose monitors: physician recommendation and documentation that the child is below 12 years OR that the patient has used conventional meters >30 days and is non-compliant due to pain sensitivity or callused fingertips.

Key Coverage Criteria

Dexcom SHARE (accessory to Dexcom G4 PLATINUM) provides remote mobile communications allowing transmission of glucose levels to up to 5 designated recipients ('followers') for remote monitoring and alert notifications (described as an accessory to Dexcom G4 PLATINUM).
Implantable continuous glucose monitoring sensors (examples studied: Senseonics/Eversense, other investigational implantable sensors) have been studied for up to 90 days (single-sensor continuous display) and in some pivotal trials demonstrated accuracy (e.g., PRECISE II MARD 8.8%; 91% sensors functional through day 90).
Continuous glucose monitoring (CGM) in general: the document cites evidence that CGM can improve glycemic control and quality of life in patients with diabetes mellitus (Dehennis et al 2016; Christiansen et al 2018) and summarizes randomized trials and systematic reviews examining CGM use in type 1 and type 2 diabetes.
Medically necessary quantities of diabetic supplies (test strips and lancets): - For members with diabetes not currently treated with insulin injections, up to 100 test strips and up to 100 lancets every 3 months are considered medically necessary. - For members with diabetes who are currently being treated with insulin injections, up to 300 test strips and up to 300 lancets every 3 months are considered medically necessary. [...]
Continued use of CGMs for children and adolescents less than 18 years of age with type 1 or type 2 diabetes.
Continuous glucose monitor and insulin pump with a low glucose suspend feature (e.g., MiniMed 630G) as an equally acceptable alternative to a standard insulin pump and CGM for medically necessary indications.

1 Active Policy

AETNA-CPB-0070, Diabetes Tests, Programs and Supplies

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A4210, Needle-free injection device, each