Coverage Policies

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Effective Date: 11/01/2010 Title: Diabetic Educationl Sessions
Revision Date: 10/01/2015 Document: BI054:00
CPT Code(s): 97802-97804, 98960-98962, 99078, G0108, G0109
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1.    Diabetic education counseling visits are generally covered for an approved comprehensive diabetic education program. 

2.     Further diabetic education sessions will be covered if medically necessary according to QualChoice criteria.

3.    Diabetic education is not covered unless administered by a licensed provider certified by the American Diabetes Association or the American Association of Diabetes Educators.

4.    Educational services are covered on a limited basis for diagnoses other than diabetes; see BI342

Medical Statement
  1. Dietary counseling and diabetic education will be covered for diabetics under the following criteria:
    1. Diabetic education is covered for one course.
    2. Dietary group counseling is not covered.
  2. Dietary counseling for other diagnoses is only covered when specifically permitted by the Summary Plan Description or Evidence of Coverage.  When permitted by the plan, coverage is available as discussed in BI342.Codes permitted are:
    1. G0108-G0109
    2. 97802-97803
    3. 98960-98962
    4. 99078
    5. 97804 is not covered

Codes Used In This BI:

97802 Medical nutrition indiv in
97803 Med nutrition indiv subseq
97804 Medical nutrition group
98960 Self-mgmt educ & train 1 pt
98961 Self-mgmt educ/train 2-4 pt.
98962 Self-mgmt educ/train 5-8 pt.
99078 Group health education
G0108 Diab manage trn per indiv
G0109 Diab manage trn ind/group

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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