Who to Refer

To qualify for DSMES services, an individual must have the following:

• Documentation of diagnosis of type 1, type 2 or gestational diabetes
• Under Medicare and many commercial payers diagnosis must be made using the following criteria:
  • Fasting Blood glucose of 126 mg/dL on two separate occasions
  • 2-Hour Post-Glucose Challenge of ≥200 mg/dL on two separate occasions
  • Random Glucose Test of >200 mg/dL with symptoms of unmanaged diabetes
• A written referral (see sample forms below) from the treating physician or qualified non-physician practitioner (including nurse practitioner, physician assistant, clinical nurse specialist or advanced nurse practitioner)
  • A new referral is required for follow up visits after one year

When to Refer

ADCES, the Association of Diabetes Care & Education Specialists and the Academy of Nutrition and Dietetics issued joint guidance on when DSMES is most critical and a referral is needed for optimal outcomes. These include:

1. At Diagnosis
2. During an annual assessment
3. When a person with diabetes faces new complicating factors
4. When there is a transition in care

Coverage

Medicare covers up to 10 hours of DSMES (referred to as diabetes self-management training - DSMT - within Medicare) as a once-in-a-lifetime benefit that must be used within 12 consecutive months once started. Each subsequent calendar year, Medicare covers up to 2 hours of DSMT with a new referral.  Most commercial insurers follow Medicare, but its best to have each person check with their insurer to verify coverage. DSMT programs may be able to assist participants with this.