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Ohio Laws and Rules
(A) The following criteria must be met to establish medical necessity for a blood glucose monitor for use by an eligible consumer in his or her personal residence:
(1) Diagnosis of “Type I” or “Type II” diabetes mellitus or gestational diabetes mellitus, with one of the following complicating conditions:
(a) Frequent checks of blood glucose required;
(b) Widely fluctuating blood sugars before mealtime;
(c) Frequent episodes of insulin reactions;
(d) Evidence of frequent significant ketosis;
(e) Recent hospitalization as a result of uncontrolled diabetes; or
(f) Current intensive insulin therapy; e.g., insulin pump, multiple daily injections.
(2) The prescriber has documented that the consumer or the consumer’s caregiver is capable of being trained to use the monitor properly. This documentation must be kept in the provider’s file and available for review at the department’s request.
(3) The monitoring device is designed for home rather than clinical use.
(B) The provider must obtain, prior to dispensing, and maintain on file a prescriber’s prescription that includes the diagnosis. In order to be eligible for reimbursement, the glucose monitor and related accessories and supplies must have been ordered by the prescriber who is treating the consumer’s diabetes.
(C) Blood glucose monitors with special features and specially designed supplies and materials to enable the visually impaired to use the equipment without assistance require prior authorization and must meet the following criteria:
(1) All criteria listed in paragraphs (A) and (B) of this rule, and
(2) A fully completed JFS 01910 (rev. 10/2006) “Certificate of Medical Necessity/Prescription Blood Glucose Monitor (Glucometer) and Supplies” (CMN) (appendix A to this rule) that is signed by an eligible prescriber and dated no more than thirty days prior to the first date of service, and
(3) Prescriber documentation that the consumer has a visual impairment severe enough to require use of this specialized glucose monitor.
(D) For reimbursement of blood glucose monitor supplies, the following criteria must be met:
(1) The prescriber must list the items, the quantity that is to be dispensed and the frequency of testing on the original prescription.
(2) The prescriber must provide a narrative diagnosis to the provider on each order for supplies that includes a statement indicating whether the consumer is being treated with insulin injections. All prescriptions for blood glucose monitor supplies must be renewed by the treating prescriber every six months and kept on file by the provider.
(3) Any requests for glucose monitor supplies that exceed the stated medicaid maximum amount as listed in appendix A to rule 5101:3-10-03 of the Administrative Code must be prior authorized before reimbursement for these supplies is authorized.
(4) It is the provider’s responsibility to document in his or her file that any consumer requesting glucose monitor supplies has not acquired supplies from another provider within the previous month of any supply request.
(5) The requirements stated in paragraph (B) of this rule.
(E) A provider will not dispense more than a two-month supply of test strips and/or lancets per date of service.
(F) Blood glucose monitors and supplies are reimbursed according to the department fee schedule contained in appendix DD to rule 5101:3-1-60 of the Administrative Code.
Appendix Certificate of Medical Necessity/Prescription Blood Glucose Monitor
See Form at http://www.registerofohio.state.oh.us/pdfs/5101/3/10/5101$3-10-17_PH_FF_N_APP1_20070330_1027.pdf
Replaces: 5101:3-10-17
Effective: 04/16/2007
R.C. 119.032 review dates: 04/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 5/1/90, 12/30/91, 7/8/93, 9/1/02