WHA

Continuous Glucose Monitors, Sensors, Transmitters, and Components - PA, NF

Indications for Prior Authorization

Criteria

Dexcom Products*, Freestyle Libre Products*

*If patient meets criteria above, please approve all CGM components at NDC list “PREFCGMPA”

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

  • ALL of the following:
    • Diagnosis of diabetes mellitus
      • AND
    • Patient is adherent to current diabetes treatment plan and participates in ongoing diabetes education and support
      • AND
    • ONE of the following:
      • Patient is being treated with glucose-lowering medication(s) (e.g., insulin)
        • OR
      • Patient has a history of problematic hypoglycemia with at least one of the following:
        • Recurrent (more than one) level 2 hypoglycemic events (glucose less than 54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan
        • Patient has a history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
Dexcom Products*, Freestyle Libre Products*

*If patient meets criteria above, please approve all CGM components at NDC list “PREFCGMPA”

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

  • ONE of the following:
    • Patient demonstrates positive clinical response as evidenced by ONE of the following:
      • Improvement in glycemic control (e.g., lower and/or maintain A1C levels)
      • Reduction or improvement in hypoglycemic events
      OR
    • Patient is being assessed by the prescriber for adherence to their CGM regimen and diabetes treatment plan
All Other Continuous Glucose Monitors, Sensors, Transmitters and Components*

*If patient meets criteria above, please approve all CGM components at GPI list “CGMPA”

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

  • ALL of the following:
    • Diagnosis of diabetes mellitus
      • AND
    • Patient is adherent to current diabetes treatment plan and participates in ongoing diabetes education and support
      • AND
    • ONE of the following:
      • Patient is being treated with glucose-lowering medication(s) (e.g., insulin)
        • OR
      • Patient has a history of problematic hypoglycemia with at least one of the following:
        • Recurrent (more than one) level 2 hypoglycemic events (glucose less than 54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan
        • Patient has a history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
      AND
    • Both of the following:
      • Minimum 90 day trial within the last 180 days, to both of the following:
        • Dexcom Products
        • Freestyle Products
        AND
      • Valid clinical rationale provided, explaining how the requested device is the only product that will provide benefit when the Dexcom and Freestyle products have not shown to be effective
All Other Continuous Glucose Monitors, Sensors, Transmitters and Components*

*If patient meets criteria above, please approve all CGM components at GPI list “CGMPA”

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

  • ONE of the following:
    • Patient demonstrates positive clinical response as evidenced by ONE of the following:
      • Improvement in glycemic control (e.g., lower and/or maintain A1C levels)
      • Reduction or improvement in hypoglycemic events
      OR
    • Patient is being assessed by the prescriber for adherence to their CGM regimen and diabetes treatment plan
    AND
  • Minimum 90 day trial to both of the following:
    • Dexcom Products
    • Freestyle Products
Continuous Glucose Monitors, Sensors, Transmitters and Components*

*If patient meets criteria above, please approve all CGM components at GPI list “CGMPA”

Non Formulary

Length of Approval: 12 Month(s)

  • ALL of the following:
    • Diagnosis of diabetes mellitus
      • AND
    • Patient is adherent to current diabetes treatment plan and participates in ongoing diabetes education and support
      • AND
    • ONE of the following:
      • Submission of medical records (e.g., chart notes) or paid claims confirming patient is being treated with glucose-lowering medication(s) (e.g., insulin)
        • OR
      • Submission of medical records (e.g., chart notes) confirming patient has a history of problematic hypoglycemia with at least one of the following:
        • Recurrent (more than one) level 2 hypoglycemic events (glucose less than 54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan
        • Patient has a history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
      AND
    • Both of the following (Applies to all products except Dexcom):
      • Submission of medical records (e.g., chart notes) or paid claims confirming minimum 90 day trial within the last 180 days, to Dexcom products
        • AND
      • Submission of medical records (e.g., chart notes) providing valid clinical rationale explaining how the requested device is the only product that will provide benefit when Dexcom products have not shown to be effective

  • Guideline ID
    GL-207303

  • Formulary
    Premium

  • Effective date
    Apr 1, 2025

  • P&T approval date

P & T Revisions

1970-01-01, 2024-06-25, 2024-06-11, 2024-01-16, 2023-12-18, 2023-12-14, 2023-11-06, 2023-10-16, 2023-08-27, 2023-07-05, 2023-06-23, 2023-04-21, 2023-01-21, 2022-09-16, 2022-09-12, 2022-04-14, 2021-09-10, 2021-07-20

  1. CMS. Provider compliance tips for glucose monitors & diabetic accessories/supplies. CMS Website. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33822. Accessed March 21, 2023.
  2. American Diabetes Association. Available at https://diabetesjournals.org/care/article/48/Supplement_1/S146/157557/7-Diabetes-Technology-Standards-of-Care-in. Accessed February 5, 2025.
  3. BigFoot Unity PDF. Available at: https://f.hubspotusercontent40.net/hubfs/5085144/PDFs/Bigfoot%20Unity%E2%84%A2%20System%20User%20Guide.pdf. Accessed May 23, 2023.
  1. People who have been using continuous glucose monitoring, continuous subcutaneous insulin infusion, and/or automated insulin delivery for diabetes management should have continued access across third party payers. Interruption of access to CGM is associated with a worsening of outcomes, therefore, it is important for individuals on CGM to have consistent access. [2]
  • 2024-06-25: 2024 Annual Review
  • 2024-06-11: update guideline
  • 2024-01-16: update guideline.
  • 2023-12-18: update product list
  • 2023-12-14: update guideline
  • 2023-11-06: update guideline
  • 2023-10-16: No criteria changes. Attached EHB formulary to guideline.
  • 2023-08-27: update guideline
  • 2023-07-05: 2023 Annual Review
  • 2023-06-23: update guideline
  • 2023-04-21: Update Guideline
  • 2023-01-21: update guideline
  • 2022-09-16: update guideline
  • 2022-09-12: guideline update
  • 2022-04-14: Update guideline
  • 2021-09-10: added GPIs for target products
  • 2021-07-20: New program.