Abbott provides this information as a courtesy, it is subject to change and interpretation. The customer is ultimately responsible for determining the appropriate codes,
coverage, and payment policies for individual patients. Abbott does not guarantee third party coverage or payment for our products or reimburse customers for claims that
are denied by third party payors.
*Check ICD-10 code list in the LCD-related Policy Article for applicable diagnoses.
†
See the Policy Specific Documentation Requirements section of the LCD-related
Policy Article.
1. Local Coverage Determination, Glucose Monitors (L33822). https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33822. 2. Glucose Monitor,
Policy Article (A52464). https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52464.
See last page for Important Safety Information. 1
1. Complete all fields on this Standard Written Order.
2. Confirm coverage criteria
1
and medical necessity documentation
2
requirements are met.
3. Send this order and the patient’s most recent medical records demonstrating coverage criteria
1,2
are met to a
DME supplier that provides the FreeStyle Libre 2 system.
Instructions
I certify that I am the physician identified in the “Physician Information” section below and hereby attest that the medical necessity information is true, accurate, and complete
to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability. The
patient/caregiver is capable and has successfully completed or will be trained on the proper use of the products prescribed on this order.
Patient Information
Patient Name: Date of Birth:
Phone: Email:
Address: City: State: ZIP:
Primary Insurance: Primary Insurance Member ID:
Secondary Insurance: Secondary Insurance Member ID:
Notes:
Date:Physician Signature:
Select, at least one, of the following documented reasons for prescribing CGM to improve beneficiary’s glycemic control
1,†2
History of problematic hypoglycemia
Insulin-treated
Medicare Standard Written Order
for Continuous Glucose Monitoring and Supplies
Physician Name: Phone:
NPI: Fax:
Address: City: State: ZIP:
Oce Contact: Notes:
Physician Information
Order Detail
FreeStyle Libre 2 Reader FreeStyle Libre 2 Sensors
Use per manufacturer guidelines, in accordance with FDA indications
for use
Duration of need: 99 months - unless specified otherwise:
Change Sensor every 14 days
Dispense up to 90 day supply
Duration of need: 99 months - unless specified otherwise:
DISPENSE AS WRITTEN
Diagnosis (ICD-10 code that supports medical necessity)
E10.9 E11.65 E10.65 E11.8 E11.9 Other*
2
FreeStyle Libre 2 DME Suppliers
Abbott provides this information as a courtesy, it is subject to change and interpretation. The customer is ultimately responsible for determining the appropriate codes,
coverage, and payment policies for individual patients. Abbott does not guarantee third party coverage or payment for our products or reimburse customers for claims that
are denied by third party payors.
Important Safety Information
Failure to use FreeStyle Libre 2 system as instructed in labeling may result in missing a severe low or high glucose event and/or making a treatment decision, resulting in
injury. If glucose alarms and readings do not match symptoms or expectations, use a fingerstick value from a blood glucose meter for treatment decisions. Seek medical
attention when appropriate or contact Abbott at 855-632-8658 or https://www.FreeStyle.abbott/us-en/safety-information.html for safety info.
The circular shape of the sensor housing, FreeStyle, Libre, and related brand marks are marks of Abbott. Other trademarks are the property of their respective owners.
© 2023 Abbott. ADC-25740 v4.0 2
Last Updated 04/2023.
Providers listed above include all DME suppliers who have contracted with Abbott Diabetes Care (ADC) to acquire FreeStyle Libre family of products directly from
ADC as of the “Last updated” date. For a complete listing of DME suppliers contracted directly with ADC go to https://www.freestyleprovider.abbott/us-en/dme.html.
FreeStyle Libre family of products may be available through other DME suppliers not listed who acquire these products indirectly.
This listing of participating suppliers are in alphabetical order and ADC has no preference on the supplier selected from the list.
DME SUPPLIER PHONE FAX REFERRAL EMAIL
Advanced Diabetes Supply 866-976-9110 760-496-0234 LibreIntakes @northcoastmed.com
Byram Healthcare/Apria 800-775-4372 866-387-1127 AbbottReferrals @byramhealthcare.com
Diabetes Management & Supplies/
AdaptHealth
Edgepark Medical Supplies 844-619-4650 866-510-6583 diabetesreferrals @cardinalhealth.com
Solara Medical Supplies/AdaptHealth 844-381-8032 800-999-7021 intakefaxes @solaramedicalsupplies.com
