Fillable MEDICARE STANDARD WRITTEN ORDER

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MEDICARE STANDARD WRITTEN ORDER

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MEDICARE
STANDARD WRITTEN ORDER
As a courtesy to its customers, Abbott provides the most accurate and up-to-date information available, but it is subject to change and
interpretation. The healthcare provider is ultimately responsible for determining the appropriate codes, coverage, and payment policies
for individual patients. Abbott does not guarantee third party coverage of payment for our products or reimburse customers for claims
that are denied by third party payors.
* Per Local Coverage Determination (L33822).
Please see https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33822&ver=26&DocID=L33822&bc=gAAAAAgAAAAA&#304 for more information.
See Indications and Important Safety Information on reverse.
1. Complete all fi elds on this Standard Written Order.
2. Use the Noridian September 2018 Physician Resource Letter (Continuous Glucose Monitors - Revised)
to confi rm coverage criteria and medical necessity documentation requirements are met.
3. Fax both this order and the patient’s most recent medical records that demonstrate coverage criteria are met
to a DME supplier that provides the FreeStyle Libre 2 system.
Instructions
I certify that I am the physician identifi ed in the “Physician Information” section above and hereby attest that the medical necessity
information is true, accurate, and complete to the best of my knowledge. I understand that any falsifi cation, 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.
Prescribed Number of Glucose Tests Per Day:
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:
Physician Information
Physician Name: Phone:
NPI: Fax:
Address: City: State: ZIP:
Date:
Physician Signature:
Current Insulin Regimen:
Multiple Daily Injections-Number Per Day:
Other:
Insulin Pump
K0554 (FreeStyle Libre 2 Reader)
*
K0553 (FreeStyle Libre 2 Sensors)
*
Length of Need: Lifetime-unless specifi ed otherwise: 1 Unit/30 Days or 3 Units/90 Days
(1 Unit = 1 month of sensor and supplies)
- Sensor site changes per manufacturer guidelines
Length of Need: Lifetime-unless specifi ed otherwise:
Order Detail
Order Date:
_____ / _____ / ________
Diagnosis (ICD10):
E10.9 E11.65 E10.65 E11.8 E11.9 Other:
FREESTYLE LIBRE 2 DME SUPPLIERS
†
As a courtesy to its customers, Abbott provides the most accurate and up-to-date information available, but it is subject to change and interpretation. The customer’s providers are
ultimately responsible for determining the appropriate codes, coverage, and payment policies for individual patients. Abbott does not guarantee third party coverage of payment for our
products or reimburse customers for claims that are denied by third party payors.
References: 1. On May 8, 2020, CMS published a second interim fi nal rule with comment, CMS-5531-IFC, that expanded the non-enforcement of clinical indications of coverage to
therapeutic continuous glucose monitors (CGMs). This IFC also clarifi ed that statutory reasonable and necessary statutory requirements are not being waived due to the PHE.
https://www.govinfo.gov/content/pkg/FR-2020-05-08/pdf/2020-09608.pdf. 2. CMS Issues Interim Final Rules with Comment (CMS-1744-IFC & CMS-5531-IFC) – COVID-19 Public
Health Emergency – Revised June 29, 2020, https://www.cgsmedicare.com/jc/pubs/news/2020/06/cope17942.html.
Indications and Important Safety Information
The FreeStyle Libre 2 Flash Glucose Monitoring System is a continuous glucose monitoring (CGM) device with real time alarms capability indicated for the management of diabetes in
persons age 4 and older.** WARNINGS/LIMITATIONS**: The System must not be used with automated insulin dosing (AID) systems, including closed loop and insulin suspend systems.
Remove the sensor before MRI, CT scan, X-ray, or diathermy treatment. Do not take high doses of vitamin C (more than 500 mg per day), as this may falsely raise your Sensor readings.
Failure to use the System according to the instructions for use may result in missing a severe low blood glucose or high blood glucose event and/or making a treatment decision that may
result in injury. If glucose alarms and readings from the System do not match symptoms or expectations, use a fi ngerstick blood glucose value to make diabetes treatment decisions. Seek
medical attention when appropriate and contact Abbott toll-free 855-632-8658 or visit ** www.FreeStyleLibre.us for detailed indications for use and safety information.
** Please refer to www.FreeStyleLibre.us for the indications and important safety information.
The circular shape of the sensor housing, FreeStyle, Libre, and related brand marks are marks of Abbott. ©2021 Abbott. ADC-25740 v2.0 01/21
DME SUPPLIER PHONE FAX REFERRAL EMAIL
Advanced Diabetes Supply 866-976-9110 760-496-0234 LibreIntakes@northcoastmed.com
Better Living Now 800-854-7515 877-262-2179 Libre@betterlivingnow.com
Bridgewater Health Supplies 800-974-2055 877-297-5127 info@bridgewaterhealthsupplies.com
Byram Healthcare
800-775-4372
Ext. 39027
866-387-1127 AbbottReferrals@byramhealthcare.com
CCS Medical 800-599-7521 800-557-8256 Libre@ccsmed.com
Diabetes Management & Supplies/
AdaptHealth
888-738-7929 504-407-2083 referrals@diabetesms.com
Edgepark Medical Supplies 844-619-4650 866-510-6583 diabetesreferrals@cardinalhealth.com
Edwards Health Care Services 800-951-1725 502-657-0237 libre@myehcs.com
J&B Medical Supply 800-737-0045 800-737-0012 providerservices@jandbmedical.com
Mini Pharmacy
888-545-6464
Option 2
800-280-2939 info@minipharmacy.net
Quest Health Solutions 877-888-7050 866-422-5283 info@questhealthsolutions.com
Solara Medical Supplies/
AdaptHealth
844-381-8032 800-999-7021 Intakefaxes@solaramedicalsupplies.com
Total Medical Supply 877-670-1120 877-670-1121 cgm@tmscares.com
United States Medical Supply 877-270-6508 866-347-8544
abbott@usmed.com
US HealthLink 855-421-2732 407-440-8122 customerservice@ushealthlink.com
Last Updated 02/2021.
Providers listed above include all DME suppliers who have contracted with ADC to acquire FreeStyle Libre family of products directly as of the “Last Updated” date who have represented
to ADC they intend to recognize the fl exibility provided by CMS. For a complete listing of DME suppliers contracted directly with ADC go to https://www.freestylelibre.us/dme-suppliers.pdf.
FreeStyle Libre family of products may be available through other 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. All DME suppliers who have contracted with ADC to
acquire FreeStyle Libre family of products directly were eligible to be listed if they indicated they will supply CGM according to the CMS PHE guidelines
†
1,2
.
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MEDICARE STANDARD WRITTEN ORDER

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Completed 12 October 2021

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