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Once a claim fits one of those recognized scenarios, confirm the following before billing: Insulin was administered in a covered clinical setting (not self-administered at home) The patient has a supporting diabetes diagnosis, such as E11.9, from the ICD-10-CM E10-E13 range Medical necessity is documented in the clinical record The insulin product is on the payers covered drug list The claim includes the required National Drug Code (NDC) where the payer demands it Reimbursement rates for J1815 under Medicare are based on the Average Sales Price (ASP) methodology, updated quarterly by CMS

doi: 10.5021/ad.2016.28.6.677

But the clinical picture is more complicated than a success story