Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus

Summary of Evidence Analysis of Evidence General Information Associated Information Sources of Information Bibliography Revision History Information Associated Documents Attachments Related Local Coverage Documents Related National Coverage Documents Public Versions Keywords Local Coverage Determination (LCD) Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus L35132 Expand All | Collapse All  Email Document  Download  Add to basket Contractor Information Contractor Name Contract Type Contract Number Jurisdiction States Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi New Mexico North Carolina Ohio Oklahoma South Carolina Tennessee Texas LCD Information Document Information LCD ID L35132 LCD Title Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus Proposed LCD in Comment Period N/A Source Proposed LCD DL35132 Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 04/17/2025 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 11/14/2014 Notice Period End Date 12/29/2014 CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. Current Dental Terminology © 2025 American Dental Association. All rights reserved. Copyright © 2025, the American Hospital Association, Chicago, Illinois. Reprod

The goal of this Local Coverage Determination (LCD) is to ensure that evidence-based medicine addressing the risks of acute and chronic complications of diabetes mellitus (DM) are integrated into the delivery of home health (HH) services for Medicare beneficiaries with Type II DM. Initial treatment of individuals diagnosed with DM must take into account many factors, including the level of hyperglycemia/hypoglycemia and comorbidities. Physicians often recommend diet, exercise and medications alone or in combination to help reduce long-term risks of hyperglycemia. Skilled nurse visits are permitted for the administration of daily insulin injections for the population of Medicare beneficiaries that are “either physically or mentally unable to self-inject insulin” and there is no other person who is able and willing to inject the beneficiary. Reasonable and necessary plans of care must contain sufficient information concerning the identified functional limitations to explain why an individual is physically or mentally unable to self-inject insulin. In the absence of another skilled service, failure to include the specific structural or functional impairments, together with the related activity limitations to support the determination that the individual beneficiary is either physically or mentally unable to self-inject insulin will result in a claim denial. Evidence-based medicine supports ascertaining glucose control and the risk of secondary conditions known to occur in individuals with DM by monitoring glucose and hemoglobin A1c (HbA1c) levels in individuals with DM. This information and its communication between the physician and HH agency caring for a given beneficiary helps ensure that a HH plan of care (POC) is not only patient-centered but also addresses prognosis - as required by the Medicare Benefit Policy Manual. Performing the HbA1c test quarterly in patients whose therapy has changed or who are not meeting glycemic goals is supported by the American Diabetes Association Standards of Medical Care in Diabetes - 2016 (ADA Standards). Based on this A/B HHH MAC's claims data and the increased risk of emergency department (ED) encounters and acute inpatient admissions related to hypoglycemia in this population, physicians and HH agencies should consider the inclusion of HbA1c testing in the HH POC. For other beneficiaries with stable glycemic control (defined as 2 consecutive HbA1c results meeting the treatment goals specified in the POC) performing the HbA1c test at least 2 times a year may be considered. The American Diabetes Association (ADA) framework for considering treatment goals recognizes that “patient characteristics/health status” are important factors when considering glycemic goals. Beneficiaries eligible for the Medicare HH benefit often have multiple coexisting chronic illnesses that would support a higher target goal for the HbA1c (e.g., Reducing Hypoglycemia-related ED visits/Inpatient Hospitalizations among Beneficiaries with DM Hypoglycemia-related ED visits and acute inpatient hospitalizations among elderly patients with DM are recognized as potentially preventable adverse drug events (ADE). The United States (U.S.) Department of Health and Human Services (HHS) Healthy People 2020, a decade-long work plan for improving the health of the U.S. population, contains a specific Medical Product Safety (MPS) objective [MPS-5.2 reduce ED visits for overdose from injectable antidiabetic agents] aimed at reducing the baseline rate by 10% by 2020. Insulin-related hypoglycemia and errors (IHEs) are especially prevalent in individuals with advanced age, limited life expectancy and frailty. This LCD seeks to help reduce these adverse events by promoting evidence-based HH plans of care.