Medical Policy Original Effective Date: April 1999 Revised Date: 07/25/2018 Page 1 of 36

Transcription

1 Page 1 of 36 Content This includes the following items: 1. Home Blood Glucose Monitors: Prior Authorization is not required. 2. Insulin pumps, cartridges and reservoirs. Prior Authorization is not required. 3. Continuous Glucose Monitoring Systems (CGMS). 4. Therapeutic shoes and inserts for individual with diabetes. Prior Authorization is not required. Disclaimer Definition Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in these criteria. Durable Medical Equipment (DME): Items that are reusable and provide support for physical limitations and disabilities, can withstand repeated use, and are used for a medical purpose, in the member s residence (excluding a skilled nursing facility or acute care hospital) under a physician s supervision The term durable medical equipment is further defined and addressed in regulation and program instructions (see 42 CFR and section of chapter 15 of the Medicare Benefit Policy Manual (Pub ), respectively). Under , durable medical equipment means equipment which: Can withstand repeated use; Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years; Is primarily and customarily used to serve a medical purpose; Generally, is not useful to a person in the absence of illness or injury; and Is appropriate for use in a patient s home, at school or at work DME items for diabetes are purchased: All plans, except ASO plans, are required by statute to cover diabetic supplies and certain DME for diabetics. Some plans do not have a DME benefit, but have a provision to cover diabetic supplies and diabetic DME. Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. Other related Medical Policies: Durable Medical Equipment (DME): Miscellaneous, MPM 4.5

2 Page 2 of 36 Durable Medical Equipment (DME): Orthotics and Prosthetics, MPM 4.6 Durable Medical Equipment (DME): Rehabilitation and Mobility Devices, MPM 4.2 Durable Medical Equipment (DME): Respiratory Devices, MPM 4.3 Durable Medical Equipment for State Coverage Insurance, MPM 4.7 Coverage Determination Durable Medical Equipment (DME) listed in the PHP Prior Authorization Guide requires prior authorization. Log on to Pres Online to submit a request: Items that do not require Prior Authorization are subject to retrospective review, and only covered for the indications listed. All durable medical equipment is subject to the limitations and exclusions of the member s specific benefit plan. For diabetic items, only PHP/PIC approved brands are covered. Items classified in DME may not be covered in every instance. Coverage is subject to the following: The equipment must be necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a body part. The patient s diagnosis justifies that the equipment or supply being requested is medically necessary. The practitioner s documentation must include the patient s diagnosis, the reason equipment is required and the practitioner s estimate of the duration of its need. Many of the following criteria refer the user to a CMS CGS DME MAC Local Coverage Determination (LCD). Unless otherwise noted, these LCDs are located at Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C, can be accessed on the Internet at: Criteria for Diabetic Supplies 1. Home Blood Glucose Monitors (BGM): Prior Authorization is not required. PHP follows CMS DME MAC guidelines in the coverage of blood glucose monitors and related supplies. Only PHP/PIC approved brands for these items are covered. All other monitors require Prior Authorization. Accu-Chek monitors are the preferred

3 Page 3 of 36 product and free to all members with diabetes (no copayment). Members or providers may call the Accu-Chek fulfillment center at to request a meter. CMS DME LCD L33822 details coverage of monitors, supplies and coding requirements, and can be accessed at the CMS website (link above). Please note: CMS LCD L33822 addresses coverage of home blood glucose monitors with special features for the visually impaired or for those with impairment of manual dexterity. These monitors require prior authorization through pharmacy staff. Presbyterian Health Plan (PHP) and Presbyterian Insurance Company (PIC) follows CMS DME MAC guidelines in the coverage of blood glucose monitors (HCPCS Code E0607) and related supplies HCPCS Codes Lancets (code A4259), blood glucose test reagent strips (code A4253), glucose control solutions (code A4256) and spring powered devices for lancets (code A4258) are covered for beneficiaries for whom the glucose monitor is covered only PHP/PIC-approved brands for these items are covered. All other monitors require Prior Authorization. Home blood glucose monitor coverage is limited to patients meeting the following conditions: 1) The patient has been diagnosed as having diabetes mellitus (Type 1 or Type 2), regardless of whether or not the beneficiary is being treated with insulin; AND 2) The patient s physician states that the patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, a responsible individual can be trained to use the equipment and monitor the patient to assure that the intended effect is achieved; AND 3) The device is designed for home rather than clinical use. National Coverage Determination (NCD) for Home Blood Glucose Monitors (40.2) and Local Coverage Determination (LCD) for Glucose Monitors (L33822) detail coverage of monitors, supplies and coding requirements and can be accessed at CMS CGS DME MAC website (link above) There is also blood glucose monitoring systems with integrated

4 Page 4 of 36 voice synthesizers, designed especially for use by those with visual impairment (HCPCS Code E2100) and impairment of manual dexterity (HCPCS Code E2101). 2. Insulin pumps, cartridges and reservoirs. Prior Authorization is not required. As required by CMS NCD and LCD L33794 an insulin infusion pump must be ordered and follow-up care rendered by a physician who manages multiple patients on continuous subcutaneous insulin infusion therapy and who works closely with a team including nurses, diabetic educators, and dieticians who are knowledgeable in the use of continuous subcutaneous insulin infusion therapy. Continued coverage of an external insulin pump and supplies requires that the patient be seen and evaluated by the treating physician at least every six months. PHP follows CMS DME MAC guidelines in the coverage of insulin pumps and related supplies. Only PHP/PIC approved brands for these items are covered. (For Medicare members only, insulin used in an insulin pump does not require a copayment. Pharmacy staff must initiate a prior authorization to allow the member to obtain the insulin from one of PHP/PIC s contracted pharmacies.) Presbyterian Health Plan (PHP) and Presbyterian Insurance Company (PIC) follows CMS DME MAC guidelines in the coverage of continuous subcutaneous insulin infusion (CSII) pumps and related supplies. Only PHP/PIC-approved brands for these items are covered. All other monitors require Prior Authorization. For Medicare beneficiaries, an insulin infusion pump must be ordered by and follow-up care rendered by a physician who manages multiple patients with CSII therapy and who works closely with a team including clinical nurse specialists, certified nurse practitioners, physician assistants, diabetic educators, clinical pharmacists, licensed nutritionists and registered dieticians, who are knowledgeable in the use of CSII. Continued coverage of an external insulin pump and supplies requires the member to be seen in-person every three (3) months. General CSII Criteria The following general requirements must be met: The patient with diabetes mellitus must be insulinopenic per the update fasting C-peptide testing requirement, or, as an alternative,

5 Page 5 of 36 must be beta cell autoantibody positive. Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110% of the lower limit of normal of the laboratory s measurement method. For patients with renal insufficiency and creatinine clearance (actual or calculated from age, gender, weight, and serum creatinine) less than or equal to 50 ml/minute, insulinopenia is defined as a fasting C-peptide level that is less than or equal to 200% of the lower limit of normal of the laboratory s measurement method. Fasting C-peptide levels will only be considered valid with a concurrently obtained fasting glucose less than or equal to 225 mg/dl. Levels only need to be documented once in the medical records. Medicare patients must meet either Criterion A or B as follows: Criterion A: The patient has completed a comprehensive diabetes education program, and has been on a program of multiple daily injections of insulin (i.e., at least 3 injections per day), with frequent self-adjustments of insulin doses for at least six (6) months prior to initiation of the insulin pump, and has documented frequency of glucose self-testing an average of at least four (4) times per day during the two (2) months prior to initiation of the insulin pump, and meets one or more of the following criteria while on the multiple daily injections regimen: Glycosylated hemoglobin level (HbA1c) > 7.0% History of recurring hypoglycemia Wide fluctuations in blood glucose before mealtimes Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or, History of severe glycemic excursions. Criterion B: The patient with diabetes mellitus has been on a pump prior to enrollment in Medicare and has documented frequency of glucose self-testing an average of at least four (4) times per day during the month prior to Medicare enrollment.

6 Page 6 of Continuous Glucose Monitoring Systems (CGMS). Examples of covered systems include Animas, DexCom, Minimed, Smiths Medical MD and FreeStyle Navigator. Only PHP/PIC approved brands are covered. Prior Authorization is required. In an effort to maintain blood glucose levels near the normal range, a diabetic patient frequently self-monitors blood glucose. However, frequent monitoring may not detect significant deviations in blood glucose, particularly for those diabetics with rapidly fluctuating glucose levels, glucose levels that fluctuate in the night or those who experience hypoglycemic unawareness. In addition, intensive insulin therapy places diabetic patients at higher risk for episodes of severe hypoglycemia. CGMS have been developed to detect trends and track patterns in glucose levels, information that can then be used to optimize insulin therapy and potentially improve glycemic control. There are several systems currently approved by the United States Food and Drug Administration (FDA) for continuous glucose monitoring purposes. These systems utilize sensor devices, which extract glucose from the interstitial fluid, and then measure and display the glucose in real-time, making it available to the patient as often as every five minutes. These readings are intended to supplement, not replace, information obtained from standard home glucose monitoring devices. An individual with diabetes mellitus frequently self-monitors blood glucose levels. Frequent monitoring may not detect significant deviations in blood glucose levels, particularly for those individuals with rapidly fluctuating glucose levels, glucose levels that fluctuate in the night or those who experience hypoglycemic unawareness. Intensive insulin therapy places these individuals at higher risk for episodes of severe hypoglycemia. CGMS have been developed to detect trends and track patterns in glucose levels, information that can then be used to optimize insulin therapy and potentially improve glycemic control. Two types CGMS have been developed. One system is designed for short term trending of blood glucose levels, (codes: A9276, A9277, A9278). These blood glucose readings are intended to supplement, not replace, information obtained from standard home glucose monitoring devices. A second system is designated as therapeutic CGM (HCPCS Code K0554) for long term blood glucose monitoring, and is designed to replace the need for finger-stick blood glucose determinations. A device must be Pricing, Data Analysis and Coding (PDAC)-certified as a therapeutic CGM to be utilized as

7 Page 7 of 36 such. When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. K0553 must not be used for supplies used with CGM coded as A9278. Therapeutic CGMs and related supplies are covered when the following coverage criteria are met: 1) The beneficiary has diabetes mellitus (see list of covered diagnoses); and, 2) The beneficiary has been using a blood glucose monitor (BGM) and performing frequent (four or more times a day) testing; and, 3) The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and, 4) The beneficiary s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and, 5) Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 6) Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. Therapeutic CGMS are covered with a specific written order prior to the delivery for specified HCPCS codes. The order must be initiated by a physician, nurse practitioner, physician assistant or clinical nurse specialist. A pharmacist clinician, working in conjunction with one of the ordering providers, can also order therapeutic CGMS and related supplies. When a therapeutic CGM (HCPCS Code K0554) is covered, the related supply allowance (HCPCS Code K0553) is also covered. National Coverage Determination (NCD) for Home Blood Glucose Monitors NCD (40.2) and Local Coverage Determination (LCD) for Glucose Monitors (L33822) detail coverage of monitors, supplies and coding requirements and can be accessed at CMS CGS DME MAC website (link above)

8 Page 8 of Therapeutic shoes and inserts for individual with diabetes. Prior Authorization is not required. PHP follows CMS DME MAC guidelines in the coverage of therapeutic shoes for diabetics. CMS DME MAC LCD L33369 details coverage and coding requirements. can be accessed at CMS. The Prescribing Practitioner is the person who actually writes the order for the therapeutic shoe, modifications and inserts. This practitioner must be knowledgeable in the fitting of diabetic shoes and inserts. The prescribing practitioner may be a podiatrist, M.D., D.O., physician assistant, nurse practitioner, or clinical nurse specialist. The prescribing practitioner may be the supplier (i.e., the one who furnishes the footwear). Therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all of the following criteria are met: 1. The beneficiary has diabetes mellitus (Reference diagnosis code section below); AND 2. The certifying practitioner has documented in the beneficiary's medical record one or more of the following conditions: AND a. Previous amputation of the other foot, or part of either foot, or b. History of previous foot ulceration of either foot, or c. History of pre-ulcerative calluses of either foot, or d. Peripheral neuropathy with evidence of callus formation of either foot, or e. Foot deformity of either foot, or f. Poor circulation in either foot; 3. The certifying practitioner has certified that indications (1) and (2) are met and that he/she is treating the beneficiary under a comprehensive plan of care for his/her diabetes and that the

9 Page 9 of 36 beneficiary needs diabetic shoes. For claims with dates of service on or after 01/01/2011, the certifying practitioner must: a. Have an in-person visit with the beneficiary during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and b. Sign the certification statement (refer to the Policy Specific Documentation Requirements section below) on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts. 4. Prior to selecting the specific items that will be provided, the supplier must conduct and document an in-person evaluation of the beneficiary. (Refer to the Policy Specific Documentation Requirements section below.) 5. At the time of in-person delivery to the beneficiary of the items selected, the supplier must conduct an objective assessment of the fit of the shoe and inserts and document the results. A beneficiary s subjective statements regarding fit as the sole documentation of the in-person delivery does not meet this criterion. If criteria 1-5 are not met, the therapeutic shoes, inserts and/or modifications will be denied as non-covered. (see Policy Specific Documentation Requirements section below), they will be denied as non-covered. Coverage Limitations For beneficiaries meeting the coverage criteria, coverage is limited to one of the following within one calendar year (January December): One pair of custom molded shoes (A5501) (which includes inserts provided with these shoes) and 2 additional pairs of inserts (A5512, A5513, or K0903); OR One pair of depth shoes (A5500) and 3 pairs of inserts (A5512, A5513, or K0903) (not including the non-customized removable inserts provided with such shoes). A modification of a custom molded or depth shoe may be covered as a substitute for an insert. Although not intended as a comprehensive list, the following are the most common shoe modifications: rigid rocker

10 Page 10 of 36 bottoms (A5503), roller bottoms (A5503), wedges (A5504), metatarsal bars (A5505), or offset heels (A5506). Other modifications to diabetic shoes (A5507) include, but are not limited to flared heels. Therapeutic Shoes for individual with Diabetes: Custom molded or extra-depth shoes and inserts for use by patients with diabetes are covered under this benefit. A custom molded shoe (A5501) is covered when the beneficiary has a foot deformity that cannot be accommodated by a depth shoe. The nature and severity of the deformity must be well documented in the supplier's records and available upon request. If a custom molded shoe is provided but the medical record does not document why that item is medically necessary, it will be denied as not reasonable and necessary. Exclusions: Appropriate codes for Therapeutic shoes for persons with Diabetes: (A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, K0903). See below for details. Comfort and convenience items are generally not covered, and include but are not limited to the following: Alcohol, alcohol wipes, Betadine, Betadine wipes, Iodine wipes, cotton swabs, peroxide or Phisohex The I-Port Injection Port Hazardous waste container for needle disposal See Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C for additional specific criteria not listed in this. Coding The coding listed in this is for reference only. Covered and non-covered procedures are included within this list. See CMS Local Coverage Determinations (LCDs) for additional coding references. Current Procedural Terminology (CPT) Codes CPT Codes Continuous glucose monitor, up to 72 hours Continuous glucose monitor, physicians interpretation and report.

11 Page 11 of 36 HCPCS Codes HCPCS Codes E0607 E0620 E2100 E2101 K0554 A9275 A9276 A9277 A9278 Glucose Monitors Equipment Home Blood glucose monitor. Following supplies are included (A4233, A4234, A4235, A4236) Skin piercing device for collection of capillary blood, laser, each Blood glucose monitor with intergrated voice synthesizer. Following supplies are included (A4233, A4234, A4235, A4236) Blood glucose monitor with integrated lancing/blood sample collection. Following supplies are included (A4233, A4234, A4235, A4236) Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system. Codes A9276 and A9277 are not used to bill for supplies used with code K0554 HOME GLUCOSE DISPOSABLE MONITOR, INCLUDES TEST STRIPS Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply Transmitter; external, for use with interstitial continuous glucose monitoring system Receiver (monitor); external, for use with interstitial continuous glucose monitoring system. K0553 must not be used for supplies used with CGM coded as A9278 HCPCS Codes A4233 A4234 A4235 A4236 A4244 A4245 A4246 Glucose Monitors Accessories/Supplies Replacement battery, alkaline (other than j cell), for use with medically necessary home blood glucose monitor owned by patient, each Replacement battery, alkaline, j cell, for use with medically necessary home blood glucose monitor owned by patient, each Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each Alcohol or peroxide, per pint Alcohol wipes, per box Betadine or phisohex solution, per pint

12 Page 12 of 36 HCPCS Codes Glucose Monitors Accessories/Supplies A4247 A4250 A4253 A4255 A4256 A4257 A4258 Betadine or iodine swabs/wipes, per box Urine test or reagent strips or tablets (100 tablets or strips) Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips Platforms for home blood glucose monitor, 50 per box Normal, low and high calibrator solution / chips Replacement lens shield cartridge for use with laser skin piercing device, each Spring-powered device for lancet, each A4259 Lancets, per box of 100 K0553 S1030 S1031 Supply allowance for therapeutic continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service. No more than 1 unit of service (UOS) for code K0553 per month is billable at a time. The following are included (E0607, E2100, E2101, A4233-A4236, A4244-A4247, A4250, A4253, A4255-A4259) Continuous noninvasive glucose monitoring device, purchase Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement and download to monitor HCPCS Code A5500 A5501 A5503 A5504 A5505 A5506 Therapeutic shoes For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe

13 Page 13 of 36 HCPCS Code A5507 A5508 A5510 A5512 A5513 K0903 Therapeutic shoes For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custommolded shoe, per shoe For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher), includes arch filler and other shaping material, custom fabricated, each For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each Diagnosis E08.00 E08.01 E08.10 E08.11 E08.21 E08.22 E08.29 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) Diabetes mellitus due to underlying condition with hyperosmolarity with coma Diabetes mellitus due to underlying condition with ketoacidosis without coma Diabetes mellitus due to underlying condition with ketoacidosis with coma Diabetes mellitus due to underlying condition with diabetic nephropathy Diabetes mellitus due to underlying condition with diabetic chronic kidney disease Diabetes mellitus due to underlying condition with other diabetic kidney complication

14 Page 14 of 36 Diabetes mellitus due to underlying condition with unspecified E diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with unspecified E diabetic retinopathy without macular edema Diabetes mellitus due to underlying condition with mild E nonproliferative diabetic retinopathy with macular edema, right Diabetes mellitus due to underlying condition with mild E nonproliferative diabetic retinopathy with macular edema, left Diabetes mellitus due to underlying condition with mild E nonproliferative diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with mild E nonproliferative diabetic retinopathy with macular edema, unspecified Diabetes mellitus due to underlying condition with mild E nonproliferative diabetic retinopathy without macular edema, right Diabetes mellitus due to underlying condition with mild E nonproliferative diabetic retinopathy without macular edema, left Diabetes mellitus due to underlying condition with mild E nonproliferative diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with mild E nonproliferative diabetic retinopathy without macular edema, unspecified Diabetes mellitus due to underlying condition with moderate E nonproliferative diabetic retinopathy with macular edema, right Diabetes mellitus due to underlying condition with moderate E nonproliferative diabetic retinopathy with macular edema, left Diabetes mellitus due to underlying condition with moderate E nonproliferative diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with moderate E nonproliferative diabetic retinopathy with macular edema, unspecified Diabetes mellitus due to underlying condition with moderate E nonproliferative diabetic retinopathy without macular edema, right E Diabetes mellitus due to underlying condition with moderate

15 Page 15 of 36 nonproliferative diabetic retinopathy without macular edema, left Diabetes mellitus due to underlying condition with moderate E nonproliferative diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with moderate E nonproliferative diabetic retinopathy without macular edema, unspecified Diabetes mellitus due to underlying condition with severe E nonproliferative diabetic retinopathy with macular edema, right Diabetes mellitus due to underlying condition with severe E nonproliferative diabetic retinopathy with macular edema, left Diabetes mellitus due to underlying condition with severe E nonproliferative diabetic retinopathy with macular edema, bilateral Diabetes mellitus due to underlying condition with severe E nonproliferative diabetic retinopathy with macular edema, unspecified Diabetes mellitus due to underlying condition with severe E nonproliferative diabetic retinopathy without macular edema, right Diabetes mellitus due to underlying condition with severe E nonproliferative diabetic retinopathy without macular edema, left Diabetes mellitus due to underlying condition with severe E nonproliferative diabetic retinopathy without macular edema, bilateral Diabetes mellitus due to underlying condition with severe E nonproliferative diabetic retinopathy without macular edema, unspecified E diabetic retinopathy with macular edema, right E diabetic retinopathy with macular edema, left E diabetic retinopathy with macular edema, bilateral E diabetic retinopathy with macular edema, unspecified E diabetic retinopathy with traction retinal detachment involving the macula, right E

16 Page 16 of 36 E E E E E E E E E E E E E E E E diabetic retinopathy with traction retinal detachment involving the macula, left diabetic retinopathy with traction retinal detachment involving the macula, bilateral diabetic retinopathy with traction retinal detachment involving the macula, unspecified diabetic retinopathy with traction retinal detachment not involving the macula, right diabetic retinopathy with traction retinal detachment not involving the macula, left diabetic retinopathy with traction retinal detachment not involving the macula, bilateral diabetic retinopathy with traction retinal detachment not involving the macula, unspecified diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified diabetic retinopathy without macular edema, right diabetic retinopathy without macular edema, left

17 Page 17 of 36 E diabetic retinopathy without macular edema, bilateral E diabetic retinopathy without macular edema, unspecified E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral E08.37X9 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, unspecified E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E Diabetes mellitus due to underlying condition with other diabetic arthropathy E Diabetes mellitus due to underlying condition with diabetic dermatitis E Diabetes mellitus due to underlying condition with foot ulcer E Diabetes mellitus due to underlying condition with other skin ulcer E Diabetes mellitus due to underlying condition with other skin

18 Page 18 of 36 E E E E08.65 E08.69 E08.8 E08.9 E09.00 E09.01 E09.10 E09.11 E09.21 E09.22 E09.29 E E E E E E complications Diabetes mellitus due to underlying condition with periodontal disease Diabetes mellitus due to underlying condition with other oral complications Diabetes mellitus due to underlying condition with hypoglycemia without coma Diabetes mellitus due to underlying condition with hyperglycemia Diabetes mellitus due to underlying condition with other specified complication Diabetes mellitus due to underlying condition with unspecified complications Diabetes mellitus due to underlying condition without complications Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) Drug or chemical induced diabetes mellitus with hyperosmolarity with coma Drug or chemical induced diabetes mellitus with ketoacidosis without coma Drug or chemical induced diabetes mellitus with ketoacidosis with coma Drug or chemical induced diabetes mellitus with diabetic nephropathy Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease Drug or chemical induced diabetes mellitus with other diabetic kidney complication Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema,

19 Page 19 of 36 unspecified Drug or chemical induced diabetes mellitus with mild E nonproliferative diabetic retinopathy without macular edema, right Drug or chemical induced diabetes mellitus with mild E nonproliferative diabetic retinopathy without macular edema, left Drug or chemical induced diabetes mellitus with mild E nonproliferative diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with mild E nonproliferative diabetic retinopathy without macular edema, unspecified Drug or chemical induced diabetes mellitus with moderate E nonproliferative diabetic retinopathy with macular edema, right Drug or chemical induced diabetes mellitus with moderate E nonproliferative diabetic retinopathy with macular edema, left Drug or chemical induced diabetes mellitus with moderate E nonproliferative diabetic retinopathy with macular edema, bilateral Drug or chemical induced diabetes mellitus with moderate E nonproliferative diabetic retinopathy with macular edema, unspecified Drug or chemical induced diabetes mellitus with moderate E nonproliferative diabetic retinopathy without macular edema, right Drug or chemical induced diabetes mellitus with moderate E nonproliferative diabetic retinopathy without macular edema, left Drug or chemical induced diabetes mellitus with moderate E nonproliferative diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with moderate E nonproliferative diabetic retinopathy without macular edema, unspecified Drug or chemical induced diabetes mellitus with severe E nonproliferative diabetic retinopathy with macular edema, right Drug or chemical induced diabetes mellitus with severe E nonproliferative diabetic retinopathy with macular edema, left E Drug or chemical induced diabetes mellitus with severe

20 Page 20 of 36 nonproliferative diabetic retinopathy with macular edema, bilateral Drug or chemical induced diabetes mellitus with severe E nonproliferative diabetic retinopathy with macular edema, unspecified Drug or chemical induced diabetes mellitus with severe E nonproliferative diabetic retinopathy without macular edema, right Drug or chemical induced diabetes mellitus with severe E nonproliferative diabetic retinopathy without macular edema, left Drug or chemical induced diabetes mellitus with severe E nonproliferative diabetic retinopathy without macular edema, bilateral Drug or chemical induced diabetes mellitus with severe E nonproliferative diabetic retinopathy without macular edema, unspecified E diabetic retinopathy with macular edema, right E diabetic retinopathy with macular edema, left E diabetic retinopathy with macular edema, bilateral E diabetic retinopathy with macular edema, unspecified E diabetic retinopathy with traction retinal detachment involving the macula, right E diabetic retinopathy with traction retinal detachment involving the macula, left E diabetic retinopathy with traction retinal detachment involving the macula, bilateral E diabetic retinopathy with traction retinal detachment involving the macula, unspecified E diabetic retinopathy with traction retinal detachment not involving the macula, right E diabetic retinopathy with traction retinal detachment not involving the macula, left E

21 Page 21 of 36 diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E diabetic retinopathy with traction retinal detachment not involving the macula, unspecified E diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right E diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left E diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, unspecified E diabetic retinopathy without macular edema, right E diabetic retinopathy without macular edema, left E diabetic retinopathy without macular edema, bilateral E diabetic retinopathy without macular edema, unspecified E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral E09.37X9 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified E09.39 Drug or chemical induced diabetes mellitus with other diabetic

22 Page 22 of 36 ophthalmic complication E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications E Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy E Drug or chemical induced diabetes mellitus with other diabetic arthropathy E Drug or chemical induced diabetes mellitus with diabetic dermatitis E Drug or chemical induced diabetes mellitus with foot ulcer E Drug or chemical induced diabetes mellitus with other skin ulcer E Drug or chemical induced diabetes mellitus with other skin complications Drug or chemical induced diabetes mellitus with periodontal E disease E Drug or chemical induced diabetes mellitus with other oral complications E Drug or chemical induced diabetes mellitus with hypoglycemia with coma E Drug or chemical induced diabetes mellitus with hypoglycemia without coma E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia E09.69 Drug or chemical induced diabetes mellitus with other specified complication E09.8 Drug or chemical induced diabetes mellitus with unspecified complications E09.9 Drug or chemical induced diabetes mellitus without

23 Page 23 of 36 complications E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complication E Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right

24 Page 24 of 36 E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified E with macular edema, right E with macular edema, left E with macular edema, bilateral E with macular edema, unspecified E with traction retinal detachment involving the macula, right E with traction retinal detachment involving the macula, left E with traction retinal detachment involving the macula, bilateral E with traction retinal detachment involving the macula, unspecified E with traction retinal detachment not involving the macula, right E with traction retinal detachment not involving the macula, left E with traction retinal detachment not involving the macula, bilateral E with traction retinal detachment not involving the macula, unspecified E

25 Page 25 of 36 with combined traction retinal detachment and rhegmatogenous retinal detachment, right E with combined traction retinal detachment and rhegmatogenous retinal detachment, left E with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified E without macular edema, right E without macular edema, left E without macular edema, bilateral E without macular edema, unspecified E10.36 Type 1 diabetes mellitus with diabetic cataract E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral E10.37X9 Type 1 diabetes mellitus with diabetic macular edema, resolved E10.39 following treatment, unspecified Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy

26 Page 26 of 36 E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E Type 1 diabetes mellitus with diabetic neuropathic arthropathy E Type 1 diabetes mellitus with other diabetic arthropathy E Type 1 diabetes mellitus with diabetic dermatitis E Type 1 diabetes mellitus with foot ulcer E Type 1 diabetes mellitus with other skin ulcer E Type 1 diabetes mellitus with other skin complications E Type 1 diabetes mellitus with periodontal disease E Type 1 diabetes mellitus with other oral complications E Type 1 diabetes mellitus with hypoglycemia with coma E Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without complications E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E Type 2 diabetes mellitus with mild nonproliferative diabetic