Palmetto GBA Local Coverage Determination for Type II Diabetes Mellitus in Effect


Beginning December 30, 2014, Palmetto GBA began a Local Coverage Determination (LCD) regarding home health plans of care for all patients with type II diabetes mellitus. This LCD, #L35413, is in effect for the states of Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, New Mexico, Ohio, Oklahoma, South Carolina, Tennessee and Texas.

The new LCD is designed to ensure that "evidence-based medicine addressing the risks of acute and chronic complications of diabetes mellitus are integrated into the delivery of home health services of Medicare beneficiaries with type II diabetes mellitus". 1

Because Medicare funded home health care must be "reasonable and necessary"2 in order to be covered, agencies are now charged with having documentation that shows evidence-based, patient-centered and medical necessity. In order to ensure coverage, the patient record should show that the patient is either physically or mentally unable to self-inject insulin and there is no other person who is able and willing to inject the patient; the results of the most recent hemoglobin A1C (HbA1c); and documentation must be legible, relevant and sufficient to justify the services billed. This documentation must be available to the Medicare Administrative Contractor (MAC) upon request.

Additional Medicare guidance states that the goal of treatment for patients with type II diabetes is to prevent acute and chronic complications. Home health nursing is one of the many treatment options for reaching this goal. Treatment also includes modification of diet, exercise and medications. Initial intervention depends on the level of hyperglycemia and comorbidities.

According to information published by Palmetto GBA, Medicare expects the use of Meformin (or a like medication, unless there is a contraindication for its use), to be the first-line therapy for patients with type II diabetes mellitus. They also state that patients who are maintained on daily insulin regimens whose blood glucose levels are poorly controlled should also be considered for treatment on Metformin.

Skilled nursing visits are permitted for daily insulin injections for those Medicare beneficiaries who are either mentally or physically unable to self-inject insulin, and there is no other person who is willing and able to inject the patients.3 Because Medicare continues to closely monitor daily insulin outliers, documentation in the patient's daily insulin chart should include standardized functional and psychological assessments that show the patient is clearly incapable of self-injections. Secondary diagnoses should also support the patient's inability to self-inject. Medicare published a list of secondary diagnoses that would help support the medical necessity of insulin outliers. In the absence of other skilled services, failure to include this specific information on patient's impairments will result in claim denial.

One of the biggest changes in policy in this LCD is the requirement that agencies have documentation of the hemoglobin A1C quarterly (and no less than every 120 days) in addition to monitoring and reporting intermittent blood glucose levels. This mandate began on December 30, 2014. This information and related communication with the physician ensures that the home health plan of care is patient-centered and addresses the prognosis. This is required to be considered "reasonable and necessary" care that decreases the risk of complications frequently associated with type II diabetes mellitus. 4

For questions, agencies should contact Palmetto at http://www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/Jurisdiction%2011%20Home%20Health%20and%20Hospice.

1 http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35413&ContrId=227&ver=5&ContrVer=1&CntrctrSelected=227*1&Cntrctr=227&name=Palmetto+GBA+(11004%2c+HHH+MAC)&DocType=Active&DocStatus=Active&LCntrctr=227*1&bc=AgACAAIAAAAAAA%3d%3d&

2 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

3 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

4 http://www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/Jurisdiction%2011%20Home%20Health%20and%20Hospice.