Continuous glucose monitors

Medical policy

Continuous Glucose Monitoring - 91466


Commercial and Medicaid patients:

Prior authorization is required for insulin pumps, continuous glucose monitors and supplies. Use Auth Request to get authorizations online.

Medicaid doesn't cover continuous glucose monitors.

Authorization requests must be submitted annually for ongoing approval of pump supplies.


Medicare patients:

Definitions

On January 12, 2017 the Centers for Medicare & Medicaid Services (CMS) issued CMS Ruling 1682R addressing the benefit category for non-adjunctive Continuous Glucose Monitoring (CGM) systems. CMS Ruling 1682R classified CGM systems into therapeutic and non-therapeutic systems.

A non-therapeutic CGM device is used as an adjunct to blood glucose monitoring (i.e., primary therapeutic decisions regarding diabetes treatment must be made with a standard home blood glucose monitor, not the CGM).

A therapeutic CGM is defined as a replacement for fingerstick blood glucose testing for diabetes treatment decisions, i.e., non-adjunctive use. At this time the Dexcom G5® Mobile Continuous Glucose Monitoring (CGM) System is the only FDA-approved CGM device classified with a "non-adjunctive" indication.

Medicare continuous glucose monitor coverage

Dexcom G5® Mobile Continuous Glucose Monitoring (CGM) is the only therapeutic CGM covered by Medicare. At this time, all other CGM systems are classified by CMS as non-therapeutic CGM systems and are not covered.

Coverage is retroeffective back to January 12, 2017.

For more details, see Local Coverage Determination 38822 and links, including limits, for Glucose Monitors, on the CMS website.

Medical criteria

CGS, the DME Medicare Administrative Contractor (MAC) with jurisdiction for the State of Michigan, has established the following criteria that members must meet to qualify for Dexcom G5®:

  • The member has diabetes mellitus; and,
  • The member has been using a home blood glucose monitor (BGM) and performing frequent (four or more times a day) BGM testing; and,
  • The member is insulin-treated with multiple daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
  • The member's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of therapeutic CGM testing results.

Medicare coverage for supplies used with the Dexcom G5® Mobile CGM System

Supplies are covered, including all items necessary for the use of the device but not limited to: CGM sensor, CGM transmitter, home blood glucose monitor and related BGM supplies (test strips, lancets, lancing device, and calibration solutions) and all batteries.

A monthly supply allowance is covered for Medicare members who have a Dexcom G5® Mobile CGM System and who meet the coverage requirements outlined on this page.

Coverage of the CGM system supply allowance is limited to those therapeutic CGM systems where the beneficiary ONLY uses a receiver classified as DME to display glucose data.

Medicare CGM monitor and supplies authorizations

No prior authorization is needed to prescribe the Dexcom G5 CGM system for patients who meet the coverage criteria.

You will need to request a pre-service organization determination (PSOD) if prescribing or filling more than the approved limit of diabetic testing supplies. The provider should:

  • Document if a member is not insulin dependent
  • Document that a PSOD must be completed, which is equivalent to original Medicare's Advance Beneficiary Notice (ABN).
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 G5 CGM system), 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 G5 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