Medical Policy
Effective Date:03/24/2005 Title:Continuous Glucose Monitoring
Revision Date:07/01/2023 Document:BI096:00
CPT Code(s):A9276, A9277, A9278, S1030, S1031, 95249, 95250, 95251
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

1.    Requests for Continuous Glucose Monitors and their supplies other than Freestyle LIbre and Dexcom systems require prior authorization. All PA requests for CGM are reviewed by QualChoice.

2.    Dexcom and Freestyle Libre systems/supplies are preferred products covered under the pharmacy benefit at Tier 2 (only for members using the QualChoice contracted PBM). All other CGM system/supplies (including Minimed) are non-preferred products, requiring PA, and are not covered under the pharmacy benefit.

3.    The Pre-authorization requests for continuous glucose monitoring require submission by the ordering provider (information on vendor request forms is not acceptable).

4.    The GlucoWatch, non-invasive glucose monitoring system, is not covered.
Medical Statement

Requests for Continuous Glucose Monitors and their supplies other than Freestyle Libre and Dexcom systems require prior authorization. All PA requests for CGM are reviewed by QualChoice.

1. Dexcom and Freestyle Libre systems/supplies are preferred products and are covered under the pharmacy benefit (for members using the QualChoice contracted PBM).  All other CGM system/supplies (including Minimed) are non-preferred and not covered under the pharmacy benefit. Long term continuous therapeutic glucose monitoring is considered medically necessary DME for members meeting all the following criteria: Diagnosis of diabetes (either Type 1 or Type 2)

a.    Use a home blood glucose monitor (BGM) and conduct four or more daily BGM tests

b.    Currently treated with insulin with multiple daily injections (at least 3) or a constant subcutaneous insulin pump

c.    Require frequent adjustments of the insulin treatment regimen, based on CGM test results

Codes Used In This BI:

A9276            Sensor, for CGMS

A9277            Transmitter, external, for CGMS

A9278            Receiver, external, for adjunctive, short-term CGMS

K0554            Receiver (monitor), dedicated for use with therapeutic glucose continuing monitor (new code 7/1/17)

S1030            Gluc monitor purchase

S1031            Gluc monitor rental
Limits
  1. GlucoWatch Biographer (Cygnus Inc., Redwood City, CA.), a glucose meter that is worn on the wrist, is considered experimental and investigational.

2.    Additional software or hardware required for downloading data from blood glucose monitors to computers for the management of diabetes mellitus is considered convenience and is not covered.

3.    Transmitters for Continuous Glucose Monitors are limited to two every 12 months. Any additional transmitter requests will require documentation of transmitter malfunction by the ordering provider.

Reference
  1. Goldstein DE, Little RR, Lorenz RA, et al. American Diabetes Association. Position statement: Tests of glycemia in diabetes. ADA Clinical Practice Recommendations 2003. Diabetes Care. 2003; 26 (suppl. 1): S106-S108. Available at: http://care.diabetesjournals.org/cgi/content/full/26/suppl_1/s106
  2. MiniMed, Inc. MiniMed Web: The MiniMed Continuous Glucose Monitoring System (CGMS). Sylmar, CA: MiniMed Inc.; 2000. Available at: http://www.minimed.com/files/cgms_web.htm.
  3. Gerritsen M, Jansen JA, Kros A, et al. Performance of subcutaneously implanted glucose sensors: A review. J Invest Surg. 1998; 11(3):163-174.
  4. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 1999; 22(suppl. 1):S32-S41.
  5. Gin H, Catargi B, Rigalleau V, et al. Experience with the Biostator for diagnosis and assisted surgery of 21 insulinomas. Eur J Endocrinol. 1998; 139(4):371-377.
  6. Tamada JA, Garg S, Jovanovic L, et al. Noninvasive glucose monitoring: Comprehensive clinical results. Cygnus Research Team. JAMA. 1999; 282(19):1839-1844.
  7. Garg SK, Potts RO, Ackerman NR, et al. Correlation of fingerstick blood glucose measurements with GlucoWatch biographer glucose results in young subjects with type 1 diabetes. Diabetes Care. 1999; 22(10):1708-1714.
  8. Cygnus, Inc. GlucoWatch® Biographer. Redwood City, CA: Cygnus; 2000. Available at: http://www.cygn.com/glucowatch.html.
  9. American Diabetes Association. Statement from the American Diabetes Association Regarding the FDA Advisory Committee`s Recommendations on GlucoWatch. Alexandria, VA: American Diabetes Association; December 7, 1999.
  10. Taking charge of diabetes. Self-care is crucial -- and widely neglected. Consumer Reports. 2001; 66(10):34-38.
  11. Jungheim K, Koschinsky T. Risk delay of hypoglycemia testing by glucose monitoring at the arm. Diabetes Care. 2001; 24(7):1303-1306.
  12. Fineberg SE, Bergenstal RM, Bernstein RM, et al. Use of automated device for alternative site blood glucose monitoring. Diabetes Care. 2001; 24(7):1217-1220.
  13. The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. Continuous glucose monitoring and intensive treatment of type 1 diabetes; NEJM; Oct 2, 2008
  14. Beck RW, et al. Continuous Glucose Monitoring Versus Usual Care in Patients With Type 2 Diabetes Receiving Multiple Daily Insulin Injections: A Randomized Trial. Ann Intern Med. 2017;167:365–374.

Addendum:

1)    Effective 07/01/2017:  Added new code and language distinguishing between adjunctive, short-term CGM and therapeutic, long-term CGM. Added clarifying verbiage that Continuous Glucose Monitor requests will need to be submitted by ordering provider office along with provider’s clinic progress notes. Requests from Vendors or on vendor request forms will not be accepted.

2)      Effective 01/01/2018:  Transmitters for Continuous Glucose Monitors are limited to two every 12 months. Any additional transmitter requests require documentation of transmitter malfunction by the ordering provider and prior authorization.

3)      Effective 1/1/2018: 2018 Code Updates. Updated Claim Statement section & Codes Used in This BI section to reflect revised CPT/HCPCS codes. The following codes were revised 1/1/18: 95250 & 95251.

4)    Effective 4/18/2018: Added information/reference showing CGM doesn’t improve outcomes with T2DM.

5)    Effective 10/01/2020: Updated coverage criteria of Dexcom and Freestyle Libre as preferred products covered under the pharmacy benefit; noted Minimed as non-preferred product.

6)    Effective 01/01/2022: Removed PA requirement reference for Freestyle Libre and Dexcom.

7)    Effective 06/01/2023: Removed PA requirement for short-term CGM codes.

8)    Effective 07/01/2023: Noted that K0553 and K0554 were deleted as of 12/31/2022.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.