CurrentAmbetter NevadaPolicy WA.CP.MP.501

Continuous Glucose Monitoring

Customize your policy alerts

Sign up for Ambetter Nevada Policy WA.CP.MP.501 alerts

Get alerted when Policy WA.CP.MP.501 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medical-necessity criteria for long-term continuous glucose monitoring for children, adults, and pregnant individuals with diabetes; short-term diagnostic and professional monitoring are excluded.

Policy Summary

PayerAmbetter Nevada

PolicyContinuous Glucose Monitoring

Policy CodePolicy WA.CP.MP.501

Change TypeAnnual reviewreferences updated

Effective DateOct 1, 2026

Last ReviewAug 1, 2026

Next Review DateNot specified

Key ActionVerify that the member meets a covered population category and all applicable clinical criteria before requesting long-term CGM coverage.

SourceLink

POLICY UPDATE CHANGES

The policy underwent an annual review with references updated.

4Covered patient categories

<19 yearsAge criterion

6 monthsType 2 management duration

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAmbetter NevadaPolicy WA.CP.MP.501

Continuous Glucose Monitoring

Customize your policy alerts

Sign up for Ambetter Nevada Policy WA.CP.MP.501 alerts

Get alerted when Policy WA.CP.MP.501 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medical-necessity criteria for long-term continuous glucose monitoring for children, adults, and pregnant individuals with diabetes; short-term diagnostic and professional monitoring are excluded.

Policy Summary

PayerAmbetter Nevada

PolicyContinuous Glucose Monitoring

Policy CodePolicy WA.CP.MP.501

Change TypeAnnual reviewreferences updated

Effective DateOct 1, 2026

Last ReviewAug 1, 2026

Next Review DateNot specified

Key ActionVerify that the member meets a covered population category and all applicable clinical criteria before requesting long-term CGM coverage.

SourceLink

POLICY UPDATE CHANGES

The policy underwent an annual review with references updated.

4Covered patient categories

<19 yearsAge criterion

6 monthsType 2 management duration

Long-Term CGM Medical Necessity

Long-term CGM medical-necessity criteria

Long-term continuous glucose monitoring is medically necessary when the individual meets any one of the following covered categories and applicable conditions.

Covered populations

Children/adolescents: The individual is less than 19 years old.<19 years
Adults with type 1 diabetes: The individual is an adult with type 1 diabetes.
Adults with type 2 diabetes
- Type 2 diabetes subcriteria
  - Uncontrolled HbA1C despite management: The individual is unable to achieve target HbA1C despite adherence to an appropriate glycemic management plan for six months, including intensive insulin therapy and testing blood glucose 4 or more times per day.6 months; blood glucose testing ≥4 times per day
  - Severe hypoglycemia despite management: The individual has one or more severe episodes of hypoglycemia despite adherence to an appropriate glycemic management plan, including intensive insulin therapy and testing blood glucose 4 or more times per day.Blood glucose <50 mg/dL or symptomatic; blood glucose testing ≥4 times per day
  - Impaired hypoglycemia awareness or communication: The individual is unable to recognize or communicate about symptoms of hypoglycemia.
Pregnancy
- Pregnancy subcriteria
  - Pregnancy with type 1 diabetes: The pregnant individual has type 1 diabetes.
  - Pregnancy with pre-existing type 2 diabetes on insulin: The pregnant individual has type 2 diabetes and was on insulin prior to pregnancy.Insulin before pregnancy
  - Insulin-requiring gestational diabetes with poor control: The pregnant individual has gestational diabetes, blood glucose is not well controlled during pregnancy, and insulin is required.HbA1C above target or episodes of hyperglycemia or hypoglycemia during pregnancy

Coding and Clinical Thresholds

HCPCS CodesHCPCS

A4238	Supply allowance for adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
A4239	Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
A9276	Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply.
A9277	Transmitter; external, for use with interstitial continuous glucose monitoring system.
A9278	Receiver (monitor); external, for use with interstitial continuous glucose monitoring system.
E2102	Adjunctive, non-implanted continuous glucose monitor or receiver.
E2103	Non-adjunctive, non-implanted continuous glucose monitor or receiver.

Pediatric/adolescent age

Age requirementLess than 19 years old

Type 2 diabetes glycemic-management duration

Required durationSix months

Applicable conditionUnable to achieve target HbA1C despite adherence to an appropriate glycemic management plan

Intensive insulin therapy monitoring

Monitoring frequencyTesting blood glucose 4 or more times per day

Therapy context

Medical Necessity Determination

Denial Risk

Failure to Meet Medical-Necessity Criteria

Long-term continuous glucose monitoring (CGM) is not medically necessary when the member does not meet a covered category and all applicable medical-necessity criteria. Coverage applies only to eligible children/adolescents, adults with Type 1 diabetes, qualifying adults with Type 2 diabetes, or qualifying pregnant individuals as specified below.

Children/adolescents: younger than 19 years.
Adults with Type 1 diabetes.
Adults with Type 2 diabetes: unable to achieve target HbA1C after six months of an appropriate glycemic management plan; experiencing severe or symptomatic hypoglycemia despite that plan; or unable to recognize or communicate hypoglycemia symptoms. The management plan includes intensive insulin therapy and blood-glucose testing at least four times daily.
Pregnancy: Type 1 diabetes; Type 2 diabetes with insulin use before pregnancy; or gestational diabetes requiring insulin with inadequate control, including above-target HbA1C or episodes of hyperglycemia or hypoglycemia.

Policy Context

This policy distinguishes self-monitoring of blood glucose from real-time continuous glucose monitoring (CGM). Self-monitoring uses blood glucose measurements at home, while real-time CGM continuously measures interstitial-fluid glucose and provides the current glucose level, as well as the direction and rate of change. The policy addresses CGM systems intended for long-term patient use, rather than systems used for short-term diagnostic or professional monitoring. Its medical-necessity guidance is based on the Washington State Health Care Authority Health Technology Assessment and Billing Guidelines.

CGM Terminology

Real-time continuous glucose monitoring

MeasurementContinuously measures interstitial-fluid glucose levels

Current informationProvides the current glucose level

Trend informationProvides the direction and rate of glucose change

Long-term patient-use CGM

Intended useDesigned for ongoing use by the patient

Distinguished fromSystems designed for short-term diagnostic or professional use