Glucose Monitors & Supplies Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for continuous blood glucose monitor HCPCS E2103, A4239 and blood glucose test strips HCPCS code A4233-A4236, A4253, A4256, A4258, A4259, and E0607 reviewed July 1 – September 30, 2024. The error rate for this quarter is 30.76%. The top 10 reasons for claim denials are as follows:
| Rank | Reason | Percent |
|---|---|---|
| 1. | No medical record documentation was received. | 43.12% |
| 2. | Medical Records and/or beneficiary testing logs do not meet the LCD requirements for billing over-utilization amounts. | 23.08% |
| 3. | The medical record documentation does not support the beneficiary had an in-person or Medicare-approved telehealth visit with their treating practitioner to assess adherence to their continuous glucose monitor (CGM) regimen and diabetes treatment plan every 6 months following the initial prescription of the CGM. | 10.14% |
| 4. | The supplier used the KX modifier incorrectly. The medical record documentation supports the beneficiary is non-insulin treated. | 3.85% |
| 5. | The documentation does not have a valid order. | 3.26% |
| 6. | The medical record documentation does not support the beneficiary had an in-person or Medicare-approved telehealth visit with their treating practitioner to evaluate their diabetes control and determined that criteria are met within 6 months prior to ordering the CGM. | 2.56% |
| 7. | Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. | 1.98% |
| 8. | The medical record documentation does not support the beneficiary has diabetes. | 1.98% |
| 9. | Payment for this item is included in the allowance for another item provided at the same time. | 1.98% |
| 10. | Quantity of supplies ordered is above normal allowable amounts and no medical records were sent in to address the need for over-utilization. Medicare requires medical records and a test log or narrative by the practitioner to support the requirements in the ‘high utilization’ section of the LCD. | 1.75% |
*The total percentage will be greater than 100% because some claims denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Blood Glucose Monitors Prepayment Edit Resources
- Continuous Glucose Monitors and Supplies Documentation Checklist

- Glucose Monitors and Supplies Documentation Checklist

- Glucose Monitors – LCD (L33822)

- Glucose Monitors – Policy Article (A52464)

- National Coverage Determination 40.2

- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)

- Supplier Manual Chapter 3 – Supplier Documentation

Updated: November 5, 2024

