Page 282 - Medicare Benefit Policy Manual

Diabetes self-management training services may be covered by Medicare only if the
treating physician or treating qualified non-physician practitioner who is managing the
beneficiary’s diabetic condition certifies that such services are needed. The referring
physician or qualified non-physician practitioner must maintain the plan of care in the
beneficiary’s medical record and documentation substantiating the need for training on an
individual basis when group training is typically covered, if so ordered. The order must
also include a statement signed by the physician that the service is needed as well as the
following:

• The number of initial or follow-up hours ordered (the physician can order less
than 10 hours of training);

• The topics to be covered in training (initial training hours can be used for the
full initial training program or specific areas such as nutrition or insulin training);
and

• A determination that the beneficiary should receive individual or group
training.

The provider of the service must maintain documentation in a file that includes the
original order from the physician and any special conditions noted by the physician.

When the training under the order is changed, the training order/referral must be signed
by the physician or qualified non-physician practitioner treating the beneficiary and
maintained in the beneficiary’s file in the DSMT’s program records.

NOTE: All entities billing for DSMT under the fee-for-service payment system or other
payment systems must meet all national coverage requirements.

300.1 - Beneficiaries Eligible for Coverage and Definition of Diabetes
(Rev. 13, 05-13-04)

Medicare Part B covers 10 hours of initial training for a beneficiary who has been
diagnosed with diabetes.

Diabetes is diabetes mellitus, a condition of abnormal glucose metabolism diagnosed
using the following criteria;

• a fasting blood sugar greater than or equal to 126 mg/dL on two different
occasions;

• a 2 hour post-glucose challenge greater than or equal to 200 mg/dL on 2 different
occasions; or