Does A4238 require prior authorization?

No, A4238 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for A4238?

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

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`A4238`, Supply allowance for adjunctive, non-implanted continuous glucose monitor

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

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted and WOPD must be received prior to delivery for DMEPOS base items that require WOPD.
Practitioner must document beneficiary (or caregiver) training/competency with the specific device and provide a prescription that evidences training and testing frequency.

For CGM initial coverage and continued coverage, the treating practitioner must document an in-person or Medicare-approved telehealth visit within six months prior to ordering and every six months thereafter to evaluate control and verify adherence to the CGM regimen.

Practitioner must certify severe visual impairment (best corrected visual acuity 20/200 or worse in both eyes) or severe manual dexterity impairment when claiming E2100/E2101 as applicable.

Suppliers must maintain proof of delivery (POD) documentation and make it available to the Medicare contractor upon request.

Suppliers must contact the beneficiary and document an affirmative refill request prior to dispensing refills and record the timing of contact (no sooner than 30 days prior to expected end of supply) and delivery timing (no sooner than 10 days prior to expected end).

Key Coverage Criteria

Beneficiary has diabetes mellitus and the treating practitioner has concluded the beneficiary (or caregiver) has sufficient training using the prescribed device as evidenced by a prescription for appropriate supplies and testing frequency.
Home blood glucose monitors with special features (HCPCS E2100, E2101) are covered when basic criteria are met and the practitioner certifies severe visual impairment (best corrected visual acuity 20/200 or worse in both eyes).
HCPCS E2101 is covered when basic criteria are met and the practitioner certifies an impairment of manual dexterity severe enough to require the special monitoring system (coverage for manual dexterity is independent of visual impairment).
Lancets (A4259), test reagent strips (A4253), glucose control solutions (A4256) and spring powered lancet devices (A4258) are covered for beneficiaries for whom the glucose monitor is covered.
A Continuous Glucose Monitor (CGM) and related supplies are covered when all initial criteria are met: beneficiary has diabetes mellitus; practitioner documents sufficient training and issues a prescription; CGM is prescribed in accordance with FDA indications; beneficiary is either insulin-treated or meets documented criteria for problematic hypoglycemia; and the treating practitioner had an in-person or Medicare-approved telehealth visit within six months prior to ordering.
When a CGM (E2102 or E2103) is covered, the related supply allowance (A4238 or A4239) is also covered consistent with the CGM coverage criteria.

6 Active Policies

ANTHEM-CG-DME-42, Continuous Glucose Monitoring Devices

L33822, Glucose Monitors

UHC-POL-continuous-glucose-monitoring-insulin-delivery-managing-diabetes, Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

CIGNA-0106, Diabetes Equipment and Supplies

UMR-POL-UMR-continuous-glucose-monitoring-insulin-delivery-managing-diabetes, Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

SUREST-POL-SUREST-continuous-glucose-monitoring-insulin-delivery-managing-diabetes, Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

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A4238, Supply allowance for adjunctive, non-implanted continuous glucose monitor