I work for Internal Medicine and having trouble with CGMS medical necessity but only for certain insurances mostly Tricare and some BCBS policies.

Medicare, Medicare Advantage paid as well as a couple of commercial like Mailhandlers and United. Most of our patient have Type II DM, but the reason we are utilizing the continuous glucose monitor option because we have label A1C levels and the provider wants to see a clearer picture if diet and/or medication management needs to be adjusted. I simply used the Type II DM code with the hyper or hypoglycemia manifestation code and I got reimbursed. All of the sudden Tricare and some BCBS policies denied for medical necessity. I talked to Tricare and BCBS but no help from them of course. On the Tricare website I found the medical necessity (Tricare Policy Manual 6010.60-M, April 1, 2015 Chapter 8, Section 5.3) which lists that Hypoglecemic unawareness (E16.2) is a covered DX. I rebilled all my denied claims to Tricare and I just posted the denial for the same reason, non-covered DX. I understand that Tricare only wants to pay for Type I DM?

Is this one of those cases where even though everyone "should" follow Medicare guidelines, they just refuse, or slow to implement this procedure? Does anyone got paid from North Region Tricare for CPT 95250 and 95251 (CGMS) for patient who did not have Type I DM?

Any help is appreciated.
Thanks,

Heni Mercer, CPC
[email protected]