Prior authorization for CGM and implantable sensors

Certain CGM and implantable sensor CPT/HCPCS codes are covered only when the policy's selection/medical necessity criteria are met; claims for these codes should be supported by documentation that the member meets the CPB selection criteria prior to billing.

• Covered codes include examples such as 95249, 95250, 95251, 0446T-0448T, G0308-G0309, A9276-A9278, A4239, and E2103.
• Ensure policy selection criteria (short-term diagnostic or long-term therapeutic indications) accompany claims for these codes.

Procedure/device codes requiring criteria

Specific procedure and durable device codes for implantable sensors and CGM systems require that the policy’s selection criteria be met; when billing these procedure/device codes, providers must ensure the medical record documents the applicable selection criteria.

• Listed procedure codes include 0446T, 0447T, 0448T, G0308, G0309.
• Device/supply codes include A9276, A9277, A9278, A4239 and S1030–S1037.

Prior authorization likely for defined populations

Technology assessments and guidelines emphasize limiting CGM use to populations with demonstrated benefit (for example, non-pregnant adults with type 1 diabetes using multiple daily injections or pump therapy); when prescribing CGM for these populations, document indications and education/training provided.

• ADA and technology assessments support CGM for adults with type 1 diabetes on intensive insulin regimens and recommend assessing readiness and providing robust education.
• Document that the member is in a population supported by evidence (e.g., adult type 1 diabetes on ≥3 daily injections or pump).

Inpatient CGM use

Use of CGM in inpatient or acutely ill settings is not supported by sufficient evidence; inpatient CGM use should be considered investigational or limited to research settings unless and until further studies establish clinical benefit.

• The ADA (2007) and systematic reviews note lack of data for acutely ill inpatients; providers should avoid routine inpatient CGM outside research.

PMA device noted — prior authorization not specified

The MiniMed 530G System is FDA-approved (PMA) as a threshold-suspend artificial pancreas device system; the CPB does not specify payer prior authorization rules for PMA devices, so providers should follow applicable plan-level requirements.

• MiniMed 530G is FDA PMA-approved for threshold suspend functionality; plan-specific prior authorization policies are not detailed in this excerpt.

Prior authorization for implantable CGM and accessories

Implantable CGM systems and remote monitoring accessories may be considered investigational or have limited evidence of outcome benefit; such devices may require prior authorization and supporting clinical justification when requested for coverage.

• Eversense implantable CGM has FDA approval but clinical outcome benefits are limited; remote accessories (e.g., Dexcom SHARE) lack demonstrated outcome improvements and may be denied.
• Providers should be prepared to supply evidence of clinical need when requesting coverage for implantable CGM or remote monitoring accessories.

Prior authorization for implantable CGM

Use of implantable CGM requires documentation of the device indication and that insertion/removal was performed as an outpatient procedure; providers should submit the outpatient procedure notes and clinical rationale when requesting coverage.

• Eversense involves outpatient implantation and FDA reviewed insertion/removal procedure safety; document procedure details and device indication in the medical record.
• Include clinical study or FDA approval rationale if coverage is requested for implantable CGM.

Prior authorization / documentation requirements for high utilization

Quarterly usual supplies are limited (non-insulin users up to 100 strips/lancets; insulin users up to 300 strips/lancets); dispensing quantities above these thresholds require physician documentation meeting the CPB’s three required criteria.

• For quantities above usual utilization, physician must document: (a) training/prescription for device and testing frequency; (b) evaluation of diabetes control within 6 months with rationale; (c) evidence that member is testing at the frequency that corroborates dispensed quantities, with updates at least every 6 months.

Prior authorization may be required per plan provisions

Plan provisions govern coverage administration; providers should follow the member’s specific plan rules because prior authorization requirements may apply at the plan level even if not specified in the CPB.

• Clinical Policy Bulletins are partial descriptions of plan benefits and do not replace plan documents; check member plan rules for prior authorization requirements.

Step requirements for long-term CGM

Long-term CGM coverage is limited to adults (≥18 years) using intensive insulin regimens (multiple [≥3] daily injections or insulin pump therapy); CGM for persons with type 2 diabetes not using intensive regimens is considered experimental/investigational.

• Document that the member is ≥18 years and using an intensive insulin regimen (≥3 daily injections or pump) when requesting long-term CGM coverage.
• Type 2 diabetes patients not on intensive regimens are not covered for long-term CGM per CPB.

Therapy sequencing considerations

When CGM is integrated with insulin pump therapies (sensor-augmented systems), these are incremental to care and require structured training and monitoring; document the training and follow-up plan when initiating combined therapies.

• Combined pump/CGM systems require patient education and monitoring; document readiness and training per ADA and technology assessment recommendations.

Consider sequencing insulin delivery changes

Initiation of pump therapy can confound assessment of CGM benefit; when both are started, document the sequencing rationale and clinical justification to support coverage decisions.

• Trials combining pump initiation with CGM make it difficult to attribute benefit; provide rationale if therapies are initiated concurrently.

Professional CGM for diagnostic evaluation

Short-term professional CGM may be used diagnostically to detect unrecognized hypoglycemia (often nocturnal) when conventional SMBG is insufficient; document the diagnostic indication and limit duration to 72 hours–1 week, with no more than two monitoring periods per 12 months.

• Document specific diagnostic indication (e.g., hypoglycemia unawareness, recurrent symptomatic hypoglycemia) and the planned monitoring duration (72 hours to 1 week).
• CPB limits short-term professional CGM to a maximum of 2 periods within 12 months.

No explicit step therapy requirements specified

This excerpt does not specify any formal step therapy mandates; providers should note that no explicit step therapy requirements are stated in the CPB text.

• Although no explicit step therapy mandates are listed, usual utilization thresholds and selection criteria functionally guide coverage decisions.

Step through standard care first

Before authorizing novel monitoring devices for foot ulcer prevention or other adjunctive technologies, consider standard care first (annual foot exam, 10-g monofilament screening) and document attempts at conventional management.

• Standard screening and preventive care (10-g monofilament, annual exam) should be documented prior to using adjunctive devices.
• Document prior outpatient or self-monitoring strategies and rationale for advancing to device-based monitoring.

Step therapy

The CPB does not state explicit step therapy mandates for CGM or related devices; providers should follow the selection criteria and documentation requirements outlined in the policy when requesting coverage.

• No formal step therapy sequence is imposed by the CPB; clinical indications, device-specific criteria, and documentation guide coverage.

Utilization thresholds as step

Usual utilization thresholds (100 strips/lancets per 3 months for non-insulin users; 300 per 3 months for insulin users) act as baseline coverage quantities; quantities above these thresholds require the CPB’s documented justification (physician training confirmation, recent evaluation, corroborating testing logs).

• Use the CPB’s three documentation criteria to support higher quarterly supply requests: prescription/training, evaluation within 6 months, and testing log or narrative.
• Ongoing excess utilization requires updated documentation at least every 6 months.

Documentation for diabetes self-care programs

Providers must order diabetes self-care education programs and include a physician-signed statement that the service is needed; programs must be delivered by recognized healthcare professionals and designed to educate about medically necessary diabetes self-care.

• Ensure the medical record contains the physician order and signed statement of medical necessity for the self-care program.
• Document that the program personnel are recognized healthcare professionals (physician, RD, RN, pharmacist).

Documentation for short-term CGM

Short-term CGM requests must document the diagnostic indication (e.g., hypoglycemia unawareness, repeated daily hypo/hyperglycemia, nesidioblastosis/PHHI) and specify monitoring duration (72 hours–1 week) with a limit of two periods per 12 months.

• Include documentation of symptoms and prior conventional testing that was insufficient to characterize hypoglycemia.
• Specify intended monitoring duration (72 hours to 1 week) and prior short-term CGM use within the past 12 months.

Documentation for long-term CGM

Long-term CGM therapeutic use requires documentation that the patient is an adult (≥18 years) using an intensive insulin regimen (≥3 daily injections or insulin pump) and either is not meeting glycemic targets or is experiencing hypoglycemia; continued use requires evidence of benefit or prescriber assessment of adherence every six months.

• Document age, insulin regimen details (≥3 injections/day or pump), current glycemic control, and history of hypoglycemia or hypoglycemia unawareness.
• For ongoing coverage, document either improved glycemic control or decreased hypoglycemia, or record prescriber adherence assessment at least every 6 months.

Coding and documentation crosswalk

Use of specific CPT/HCPCS codes for CGM procedures, supplies, implantable sensors, and accessories should be supported by meeting the CPB selection criteria; ensure the claim documentation crosswalks the billed codes to the applicable selection criteria.

• Examples of codes requiring selection criteria include 95249–95251, 0446T–0448T, A4239, A9276–A9278, G0308–G0309, S1030–S1037, and E2103.
• Attach supporting clinical documentation showing which CPB criteria are satisfied when submitting claims.

Document patient readiness and training

Assess and document patient readiness, education, training, and adherence when prescribing CGM; evidence of individualized training and follow-up supports medical necessity.

• Document that robust diabetes education and support were provided and that the patient’s ability to use and adhere to CGM was assessed.
• Record follow-up plans and adherence assessments in the medical record.

Recommended supporting data

When submitting CGM clinical data to support coverage (short-term or long-term), include paired sensor readings with capillary blood glucose values, monitoring durations (e.g., 72-hour or 14-day), and event counts such as hypoglycemic episodes or time-in-range summaries.

• Provide sensor logs paired with SMBG calibration checks and summaries of hypoglycemic events or time-in-range metrics.
• Include duration of monitoring and summary interpretation to justify changes in management.

Calibration/documentation requirement (device labeling)

Follow device labeling for calibration and documentation requirements (for example, GlucoWatch labeling requires fingerstick calibration each time the device is worn); include calibration records when relevant.

• For devices that require calibration, document fingerstick calibration readings and dates in the medical record.
• Note device-specific limitations (e.g., GlucoWatch cannot be used alone for insulin-dosing decisions).

Supporting clinical evidence documentation

For wound-temperature monitoring and implantable CGM, providers should document supporting clinical evidence such as measured reliability, sensor lifespan, sensitivity/specificity, and clinical justification to demonstrate medical necessity.

• Include study results or device performance metrics (e.g., sensor life span, MARD, sensitivity/specificity) when requesting coverage for investigational devices.
• Document potential procedure-related adverse events and outpatient procedure notes for implantable sensors.

Procedure and device documentation

Document procedural details and device safety for implantable CGM insertions/removals; include outpatient procedure notes, informed consent, and any device-related adverse event monitoring in the medical record.

• Record insertion/removal operative notes, device lot/serial numbers, and post-procedure follow-up.
• Document counseling on device risks (infection, bleeding, skin reactions) as noted in FDA review.

Required physician documentation for >usual supply quantities

When requesting quantities of supplies exceeding usual utilization limits, the physician must document (a) training/prescription for device and testing frequency, (b) evaluation of diabetes control within 6 months prior to the order with rationale, and (c) evidence that the member is testing at a frequency that corroborates dispensed quantities; renew this documentation at least every six months for ongoing excess utilization.

• Maintain a testing log or narrative that demonstrates actual testing frequency.
• Keep documentation of the physician’s recent evaluation and explicit reason for additional supplies in the medical record.

Providers are responsible for medical advice and plan verification

Providers are responsible for medical advice and treatment; the CPB is a partial description of plan benefits and not a contract — verify member plan benefits and prior authorization rules before ordering devices or services.

• Check the member’s plan documents for coverage specifics, prior authorization requirements, and whether supplies are covered under pharmacy or medical benefits.

Non-covered/convenience items may be denied

Items listed as non-covered or convenience features (for example, I-Port, hypoglycemic wristband alarms, and cellular-enabled wireless attachments) risk denial if billed to medical coverage or when plan excludes them; verify coverage pathway (medical vs pharmacy) and plan exclusions before ordering.

• Aetna does not cover wireless transmission attachments or provides no additional reimbursement for integrated wireless features considered convenience.
• Confirm whether a device is considered a convenience item or excluded by the member’s plan prior to billing.

Coding-based denial risks

Claims with certain ICD-10 principal diagnoses (for example, E16.9 and P70.3–P70.4) are listed as not covered for the CPB indications and may be denied; ensure appropriate diagnosis coding that aligns with the CPB selection criteria when submitting claims.

• E16.9 (Disorder of pancreatic internal secretion, unspecified [nesidioblastosis]) and P70.3–P70.4 (neonatal hypoglycemia codes) are listed as not covered for CPB indications.
• Use diagnosis codes that match the covered indications (e.g., E10.x, E11.x) and document selection criteria.

Population-specific limits may trigger denial

Evidence is insufficient for broad CGM use in children, adolescents, and pregnant women; use in these populations may not meet technology assessment criteria and could be denied unless strong selection criteria and documentation are provided.

• CTAF and other assessments found conclusive benefit mainly in adults and noted adherence issues in younger populations; document clinical rationale thoroughly if prescribing in these subgroups.

Inpatient use unsupported

Use of CGM and related accessories in the inpatient/acute setting is unsupported by current evidence and may be considered investigational outside research; expect potential denial for inpatient claims for CGM unless part of an approved study.

• ADA and systematic reviews note insufficient inpatient data; document research protocol if device use is part of a study.

Research-use devices

Devices used for research only (for example, Scout DS for AGE measurement) and interventions without demonstrated clinical benefit may not meet coverage criteria; provide clinical evidence if requesting coverage for research-use technologies.

• Scout DS system is currently used for research and is not intended to replace standard diagnostic tests; coverage is unlikely without demonstrated clinical effectiveness.

High utilization documentation requirements

Dispensing quantities of supplies that exceed utilization guidelines without the CPB-required physician documentation (training/prescription, evaluation within 6 months, and testing logs/narrative) may lead to denial of coverage.

• If requesting higher-than-usual quarterly supplies, include the three required documentation elements and ensure records are updated at least every 6 months for ongoing excess use.