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This policy governs prior authorization for initial and renewal coverage of continuous glucose monitors and supplies for members with insulin-treated diabetes. It applies to provider-submitted requests requiring documentation of appropriate diabetes treatment, education, CGM utilization, and clinical benefit.
Policy Summary
PayerAdvanced Health
PolicyContinuous Glucose Monitor (CGM) Use Criteria
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionSubmit prior authorization documentation for initial or renewal CGM requests, including applicable treatment, education, utilization, and clinical benefit evidence.
No material clinical or coverage changes in this revision.
6 monthsMaximum initial approval period
12 monthsMaximum renewal approval period
HbA1c ≥ 8.0%Qualifying risk or need factor
50%Minimum renewal CGM use
Freestyle
Policy Summary
PayerAdvanced Health
PolicyContinuous Glucose Monitor (CGM) Use Criteria
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionSubmit prior authorization documentation for initial or renewal CGM requests, including applicable treatment, education, utilization, and clinical benefit evidence.
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Preferred initial CGM brand
Continuous Glucose Monitor Coverage Criteria
Continuation or Renewal Therapy
Renewal requests are covered when all renewal criteria are met.
Continued qualifying insulin therapy: Submitted chart notes and medication fill history support continued use of insulin injections for Type 1 diabetes or continued use of short-acting insulin injections for Type 2 diabetes.
CGM utilization
Data-tracking software documentation supports use of the CGM device for at least 50% of the previous 90 days.
Prescriber attestation supports CGM use for at least 50% of the previous renewal period.
Ongoing clinical benefit
Evidence may include
Improved A1c.
Reduced hypoglycemia or hyperglycemia.
Other documented ongoing clinical benefit.
Provider follow-up confirms ongoing CGM use and benefit.
Renewal approval outcome: When all renewal criteria are met, approve CGM coverage.Up to 12 months
Initial CGM coverage criteria are not met when the member does not have Type 1 diabetes, insulin-dependent Type 2 diabetes, or gestational diabetes treated with insulin.
An initial request does not meet coverage criteria when the applicable insulin requirement is not met: members with Type 1 or insulin-treated gestational diabetes must be on insulin therapy using any regimen, while members with Type 2 diabetes must use short-acting insulin injections. Coverage criteria also require provider attestation of CGM-specific diabetes education and integration of CGM data into care, plus at least one qualifying risk or need factor, such as HbA1c ≥ 8.0%, frequent or severe hypoglycemia, impaired hypoglycemia awareness, or diabetes-related complications.
A renewal request does not meet coverage criteria when continued qualifying insulin use is not supported, CGM utilization is below 50% of the previous 90 days or below 50% of the previous renewal period, ongoing clinical benefit is not documented, or provider follow-up does not confirm continued CGM use and benefit.
Qualifying Clinical and Utilization Thresholds
Glycemic control risk factor
ThresholdHbA1c ≥ 8.0%
Applies toInitial CGM coverage requests
RequirementDocumentation must show at least one qualifying risk or need factor
CGM utilization for renewal
Previous 90 daysAt least 50% CGM use
Previous renewal periodAt least 50% CGM use
DocumentationData-tracking software documentation and prescriber attestation are required
Authorization, Documentation, and Denial Risks
Prior Authorization
Prior Authorization and Approval Periods
Prior authorization is required for both initial CGM requests and renewals. Initial approval may be granted for up to 6 months; renewal approval may be granted for up to 12 months when all applicable criteria and documentation requirements are met.
Initial requests: maximum approval period of 6 months.
Renewal requests: maximum approval period of 12 months.
Documentation Required
Initial Request Documentation
For an initial request, submit documentation supporting the member’s qualifying diabetes diagnosis, applicable insulin regimen, CGM-specific diabetes education, and integration of CGM data into care. The provider must attest that the member received or will receive the required education and that CGM data will be integrated into treatment planning.
Diagnosis of Type 1 diabetes, Type 2 diabetes treated with insulin, or gestational diabetes treated with insulin.
Policy Rationale
The policy prioritizes CGM for members with insulin-treated diabetes who are at increased risk for hypoglycemia, poor glycemic control, or diabetes-related complications and are expected to benefit clinically from continuous glucose data integrated into treatment planning. Coverage therefore emphasizes appropriate patient selection, provider oversight, diabetes education, continued device utilization, and documented clinical benefit.
Current insulin treatment: any insulin regimen for Type 1 or gestational diabetes; short-acting insulin injections for Type 2 diabetes.
Provider attestation regarding CGM-specific diabetes education and integration of CGM data into care.
Documentation of at least one qualifying risk or need factor: HbA1c ≥ 8.0%, frequent or severe hypoglycemia, impaired hypoglycemia awareness, or diabetes-related complications such as neuropathy, retinopathy, or nephropathy.
Denial Risk
Initial Request Eligibility Deficiencies
An initial request may be denied as not meeting criteria when the submitted record does not support a qualifying diabetes diagnosis, the required insulin treatment, CGM-specific diabetes education and provider attestation, or at least one qualifying risk or need factor.
No qualifying diabetes diagnosis or no documentation that gestational or Type 2 diabetes is treated with insulin.
Type 1 or gestational diabetes without current insulin therapy, or Type 2 diabetes without short-acting insulin injections.
Missing provider attestation regarding CGM-specific education or integration of CGM data into care.
No documentation of HbA1c ≥ 8.0%, frequent or severe hypoglycemia, impaired hypoglycemia awareness, or diabetes-related complications.
Documentation Required
Renewal Documentation
For renewal, submit current chart notes and medication fill history, CGM utilization data from device-tracking software, and prescriber attestation. The record must demonstrate continued qualifying insulin use, CGM use for at least 50% of the previous 90 days, and prescriber-supported use for at least 50% of the previous renewal period.
Chart notes and medication fill history supporting continued insulin injections for Type 1 diabetes or continued short-acting insulin injections for Type 2 diabetes.
Data-tracking software documentation showing CGM use for at least 50% of the previous 90 days.
Prescriber attestation supporting CGM use for at least 50% of the previous renewal period.
Provider follow-up documentation confirming ongoing CGM use and benefit.
Denial Risk
Renewal Documentation or Benefit Deficiencies
A renewal may be denied when continued qualifying insulin use, CGM utilization, clinical benefit, or required documentation is insufficient. The record must show ongoing benefit—such as improved A1c or reduced hypoglycemia or hyperglycemia—and provider follow-up confirming continued use and benefit.
Chart notes or medication fill history do not support continued qualifying insulin injections.
CGM use is below the required 50% threshold or tracking-software documentation or prescriber attestation is missing.
No evidence of ongoing clinical benefit, such as improved A1c or reduced hypoglycemia or hyperglycemia.
Provider follow-up does not confirm ongoing CGM use and clinical benefit.