Continuous glucose monitors

Medical policy

Commercial members

Most fully funded group and individual members must obtain CGMs and related supplies through pharmacy, with the exception of Medtronic, which must be obtained through DME. Some self-funded group members and a few fully funded group members, depending on their plan*, may also be able to obtain CGMs through DME.

Continuous glucose monitors obtained through pharmacy

Members who currently use insulin (have a pharmacy claim in the last 6 months) will be able to obtain the Dexcom or Freestyle Libre at the pharmacy without a prior authorization. Otherwise, a prior authorization for CGMs will be required. Requests can be made using the pharmacy prior authorization form.

Continuous glucose monitors obtained through DME (Medtronic and self-funded group members only)

Participating providers: Use our Auth Request tool, which will direct your request for healthcare review. In many cases, an authorization number can be provided immediately. Authorization requests must be submitted annually for ongoing approval of pump supplies.

Non-participating providers: Request authorizations using the general Medical prior authorization form.

*You may assume that CGMs are non-covered items under DME/medical benefits unless coverage is noted under “Durable Medical Equipment” under “Medical Benefits” in prism.

Medicaid members

Prior authorization through DME is required for the following if standards of coverage and documentation requirements are met:

Type I diabetes
Diabetes in pregnancy, childbirth and the puerperium period (insulin or non-insulin treated)

Prior authorization is required for all other conditions and clinical scenarios where use of CGMs may be beneficial, including but not limited to Type II diabetes.

Medicare members

Definitions

Coverage of a CGM system supply allowance (code A4238 or A4239) is available for CGM systems when the beneficiary uses a stand-alone receiver or insulin infusion pump classified as DME to display glucose data. In addition, Medicare coverage is available for a CGM system supply allowance if a non-DME device (watch, smartphone, tablet, laptop computer, etc.) is used in conjunction with the durable CGM receiver (code E2102 or E2103). The following are examples of this provision:

Medicare coverage of a CGM supply allowance is available when a beneficiary uses a durable CGM receiver to display their glucose data and also transmits that data to a caregiver through a smart phone or other non-DME receiver.
Medicare coverage of a CGM system supply allowance is available when a beneficiary uses a durable CGM receiver on some days to review their glucose data but uses a non-DME device on other days.

If a beneficiary never uses a DME receiver or insulin infusion pump to display CGM glucose data, the supply allowance is not covered by Medicare.

Go to the Authorizations section for details on Medicare non-coverage/PSODs
(Medicare CGM billing)

Payable:

When the monitor prescribed is a therapeutic continuous glucose monitor (the Dexcom G6 CGM system or Freestyle Libre), and when the patient meets all coverage criteria in effect on the date of service of the initial claim.

Not payable:

Non-DME devices (smart phone, tablet, etc.) used as the display device, either separately or in combination with a receiver classified as DME; these are considered by Medicare to be non-medical items even if serving a medical purpose.
Medical supplies used with non-covered equipment
Equipment or supplies/accessories obtained prior to Medicare eligibility

Member cost share

The Dexcom G6, G7, Freestyle Libre and supplies fall under the member's Priority Health Medicare DME benefit. Applicable member cost share, depending on the member's plan, applies to both the device and supplies.

Coding

Refer to the medical policy and LCD, above. Applicable HCPCS modifiers for glucose monitors and supplies:

CG - Policy criteria applied
EY - No physician or other licensed health care provider order for this item or service
KS - Glucose monitor supply for diabetic beneficiary not treated by insulin
KX - Requirements specified in the medical policy have been met