Answer A is correct: 55.1% chose this answer, “When scheduling, JM requested an individual appointment” Answer A is correct; it does NOT justify individual DSMES. Although diabetes care should be patient-centered, patient preference alone does not meet Medicare criteria for individual DSMES. Medicare requires the referring provider document justification of barriers to group learning which can include clinical, educational, or psychosocial need.

Answer B is incorrect: 12.74% chose this answer, “The referral for DSMES stated JM has a language barrier” Answer B is incorrect and does justify individual DSMES. Language barriers can significantly limit participation in group DSMES. Medicare recognizes a referral with stated language and communication needs as valid justification for an individual visit.

Answer C is incorrect: 15.61% chose this answer, “A group DSMES class is not available within the next 3 months” Answer C is incorrect and does justify individual DSMES. Medicare will approve individual DSMES if no group class is available for two months or longer from the date on the referral.

Answer D is incorrect: 16.56% chose this answer, “JM was referred for training on starting insulin therapy” Answer D is incorrect and does justify individual DSMES. A referral for initiation of insulin therapy requires individualized instruction. This can include injection technique, dose adjustment, hypoglycemia prevention, and problem-solving. Medicare considers this
an appropriate reason for individual DSMES.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!