CurrentArizona Health Care Cost Containment SystemPolicy N/A

Continuous Blood Glucose Monitoring Devices (CGM)

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This prior authorization guideline governs coverage of continuous glucose monitors, sensors, and transmitters for AHCCCS Medicaid members in Arizona, including preferred and nonpreferred product criteria, reauthorization, quantity limits, billing instructions, and step therapy.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyContinuous Blood Glucose Monitoring Devices (CGM)

Policy CodePolicy N/A

Change TypeAdministrative updateno material clinical or coverage change

Effective DateMarch 20, 2026

Next Review DateN/A

Key ActionFor nonpreferred CGM requests, submit medical records documenting that the member tried and failed the FreeStyle Libre system.

SourceLink

POLICY UPDATE CHANGES

The internal prior authorization reviewer processing note was updated on March 20, 2026.

12 monthsApproval period

>7.0%HbA1c threshold

72 hoursShort-term CGM use

3/30 daysDexcom sensors

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CurrentArizona Health Care Cost Containment SystemPolicy N/A

Continuous Blood Glucose Monitoring Devices (CGM)

Customize your policy alerts

Sign up for all Arizona Health Care Cost Containment System policy alerts

Know when Arizona Health Care Cost Containment System releases new policies or updates existing guidance.

Monitor payer policy activity

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

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyContinuous Blood Glucose Monitoring Devices (CGM)

Policy CodePolicy N/A

Change TypeAdministrative updateno material clinical or coverage change

Effective DateMarch 20, 2026

Next Review DateN/A

Key ActionFor nonpreferred CGM requests, submit medical records documenting that the member tried and failed the FreeStyle Libre system.

SourceLink

POLICY UPDATE CHANGES

The internal prior authorization reviewer processing note was updated on March 20, 2026.

12 monthsApproval period

>7.0%HbA1c threshold

72 hoursShort-term CGM use

3/30 daysDexcom sensors

FreeStyle Libre sensors

2Required claim flags

Continuous Glucose Monitor Coverage Criteria

Preferred CGM Initial Authorization

Preferred CGM initial authorization is covered when at least one pathway is met.

Preferred initial authorization pathways

Established closed-loop pump: Member is already established on an integrated closed-loop insulin pump system.
The current CGM product may be approved. Members starting a closed-loop insulin pump system must obtain a new PA if changing CGM devices.
Insulin-dependent FreeStyle Libre pathway: Member is insulin dependent, confirmed by paid insulin claims within the past 60 days, and the request is for a FreeStyle Libre product.Paid insulin claim within past 60 days
FreeStyle Libre products may adjudicate without a prior authorization submission when insulin dependence is confirmed in the member’s PBM profile.
Clinical-need pathway
- Qualifying clinical indication: Meet one of the following: Type I or II diabetes mellitus with frequent insulin adjustments based on blood glucose monitoring or CGM results; gestational diabetes; hypoglycemia unawareness; documented postprandial hyperglycemia; documented recurrent diabetic ketoacidosis; or short-term use to determine baseline insulin levels before insulin pump initiation.Short-term use: 72 hours
  The diabetes diagnosis and frequent-adjustment pathway requires both a diabetes diagnosis and frequent insulin adjustments.
- Glycemic or diagnosis criterion: Meet one of the following: hemoglobin A1c greater than 7.0%; frequent hypoglycemic episodes supported by submitted chart documentation; or a diagnosis not defined by elevated hemoglobin A1c or frequent hypoglycemia, such as gestational diabetes.HbA1c > 7.0%
- Diabetes education: Provider attests that the member is enrolled in or has completed a comprehensive diabetes education program.

Nonpreferred CGM Initial Authorization

Nonpreferred CGM initial authorization requires submission of medical records documenting all applicable requirements.

Nonpreferred initial authorization pathways

Established closed-loop pump: Medical records document that the member is already established on an integrated closed-loop insulin pump system.
The current CGM product may be approved. Members starting a closed-loop insulin pump system must obtain a new PA if changing CGM devices.
Nonpreferred product clinical-need pathway
- Qualifying clinical indication: Meet one of the following: Type I or II diabetes mellitus with insulin dependence demonstrated by paid claims within the past 60 days and frequent insulin adjustments based on blood glucose monitoring or CGM results; gestational diabetes; hypoglycemia unawareness; documented postprandial hyperglycemia; documented recurrent diabetic ketoacidosis; or short-term use to determine baseline insulin levels before insulin pump initiation.Short-term use: 72 hours
  Supporting documentation is required for the specified clinical diagnoses and frequent-adjustment pathway.

CGM Reauthorization

Reauthorization is covered when all continuing-use criteria are met.

CGM reauthorization: Member is using the same continuous glucose monitoring device on a regular basis, as evidenced by the member’s claims history and the provider’s chart notes, and has shared device readings with a physician or healthcare professional for review as part of overall diabetes management.

Approval length is 12 months.

Quantity-Limit Override

Quantity-limit requests are covered only when the applicable criteria and product-specific limits are met.

Quantity-limit override requirements

Vacation override and adherence: Request is for a vacation override and the member is adherent to using the device.
Product-specific quantity limits: Requested quantities do not exceed the applicable product-specific limit for the supply period.Dexcom G6 or G7 sensors: maximum 3 sensors/30 days; FreeStyle Libre 2, 3, or 3 Plus/3+ sensors: maximum 2 sensors/28 days; Guardian Sensor 3 or 4: maximum 5 sensors, 1 box/35 days; Simplera sensors: maximum 5 sensors, 1 box/24 days; Dexcom G6 or G7 transmitters: maximum 1 transmitter/90 days; Dexcom G6 receiver: maximum 1 receiver/365 days.

General Coverage Requirements

Services are covered only when all general requirements are met.

General coverage requirements: The service must be medically necessary, cost effective, federally reimbursable, and state-reimbursable.

AHCCCS Rule R9-22-202 and corresponding federal regulations at 42 CFR Part 447 are cited for these requirements.

Requests for additional transmitter or sensor quantities are excluded when they are not for a vacation override. Product-specific quantity limits continue to apply.

A requested CGM product is excluded from approval when the member is below the product’s FDA-approved age. New products must not be approved for use below their FDA-approved age.

A request for a nonpreferred CGM is not medically necessary unless the submission documents that the member tried and failed the FreeStyle Libre system and meets the applicable qualifying clinical, glycemic, diabetes-education, and age requirements.

Requests that exceed the applicable product-specific quantity limits are not medically necessary unless they qualify for a vacation override and the member is adherent to using the device. Limits include maximum covered quantities for sensors, transmitters, and receivers based on the product and supply period.

Product, Diagnosis, and Quantity Coding

NDC List for Preferred CGM ProductsNDCCovered

57599080300	FREESTY LIBR MIS 2 READER
57599000021	FREESTYLE MIS RECEIVER
57599000200	FREESTYLE MIS READER
57599082000	FREESTY LIBR RECEIVER
57599082001	FREESTY LIBR RECEIVER
57599081800	FREESTY LIBR RECEIVER
57599084400	FREE LIBRE3 KIT PLUS/SEN
57599084401	FREE LIBRE3 KIT PLUS/SEN
57599083500	FREE LIBRE2 KIT PLUS/SEN
57599083501	FREE LIBRE2 KIT PLUS/SEN

1–10 of 12

1/2

Preferred CGM product identifiersNDCCovered

AZMFR3	NDC list used to approve preferred FreeStyle Libre products at the NDC level
97202012026200	*CONTINUOUS BLOOD GLUCOSE SYSTEM RECEIVER
97202012046300	*CONTINUOUS BLOOD GLUCOSE SYSTEM / SENSOR

GPI Lists for NonPreferred CGM ProductsHCPCSCovered

AZMCGMNP	GPI list used to approve nonpreferred CGM products at the GPI level
97202012026200	*CONTINUOUS BLOOD GLUCOSE SYSTEM RECEIVER
97202012046300	*CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR
97202012066300	*CONTINUOUS BLOOD GLUCOSE SYSTEM TRANSMITTER

Qualifying diagnoses and clinical indicationsICD-10

Type I Diabetes Mellitus	Type I Diabetes Mellitus
Type II Diabetes Mellitus	Type II Diabetes Mellitus
Gestational Diabetes	Gestational Diabetes
Hypoglycemia Unawareness	Hypoglycemia Unawareness
Postprandial Hyperglycemia	Postprandial Hyperglycemia
Recurrent Diabetic Ketoacidosis	Recurrent Diabetic Ketoacidosis

Hemoglobin A1c

MeasureHemoglobin A1c

Threshold> 7.0%

Coverage useOne qualifying glycemic criterion for certain CGM requests

Short-Term CGM Use

UseShort-term CGM before insulin pump initiation

Duration72 hours

Purpose

Authorization, Documentation, and Claim Processing

Prior Authorization

CGM Prior Authorization and Approval Period

Continuous glucose monitor (CGM) requests are subject to prior authorization unless the applicable preferred-product exception applies. Initial and reauthorization approvals are generally issued for 12 months; a new PA is required when a member starting on an integrated closed-loop insulin pump system changes CGM devices.

Initial authorization: 12 months.
Reauthorization: 12 months.
Freestyle Libre products may adjudicate without a PA submission when insulin dependence is confirmed by paid insulin claims in the member’s PBM profile.

Prior Authorization

Nonpreferred CGM Authorization

For a nonpreferred CGM request, submit medical records documenting all applicable approval criteria. Records may include chart notes, laboratory results, and other supporting clinical documentation.

Document the clinical indication and qualifying diagnosis or condition.

Policy Scope

This guideline addresses continuous glucose monitors, sensors, and transmitters used in diabetes management and selected related circumstances. Coverage may apply to insulin-dependent Type I or Type II diabetes, gestational diabetes, hypoglycemia unawareness, documented postprandial hyperglycemia, recurrent diabetic ketoacidosis, and short-term CGM use to establish baseline insulin levels before insulin pump initiation. Coverage considerations include clinical need, glycemic findings, diabetes education, FDA-approved age, ongoing device use, and sharing device readings with a treating clinician.

Clinical Definitions

Hypoglycemia Unawareness

TermHypoglycemia Unawareness (HU)

NeuroglycopeniaLow blood glucose in the brain occurring before autonomic warning symptoms appear

Impaired awarenessFailure to sense a significant fall in blood glucose below normal levels

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyContinuous Blood Glucose Monitoring Devices (CGM)

Policy CodePolicy N/A

Change TypeAdministrative updateno material clinical or coverage change

Effective DateMarch 20, 2026

Next Review DateN/A

Key ActionFor nonpreferred CGM requests, submit medical records documenting that the member tried and failed the FreeStyle Libre system.

SourceLink

On This Page

FDA-approved age: Member meets the FDA-approved age for the requested product.FDA-approved age

New products entering the market shall not be approved below the FDA-approved age.

Glycemic or diagnosis criterion: Meet one of the following: hemoglobin A1c greater than 7.0%; frequent hypoglycemic episodes supported by submitted chart documentation; or a diagnosis not defined by elevated hemoglobin A1c or frequent hypoglycemia, such as gestational diabetes.HbA1c > 7.0%

Diabetes education: Provider attests that the member is enrolled in or has completed a comprehensive diabetes education program.

FDA-approved age: Member meets the FDA-approved age for the requested product.FDA-approved age

New products entering the market shall not be approved below the FDA-approved age.

Determine baseline insulin levels prior to insulin pump initiation

Dexcom G6 or G7 Sensors

ProductsDexcom G6 or G7 sensors

Maximum quantity3 sensors

Supply period30 days

Dexcom G6 or G7 Transmitters

ProductsDexcom G6 or G7 transmitters

Maximum quantity1 transmitter

Supply period90 days

Dexcom G6 Receiver

ProductDexcom G6 receiver

Maximum quantity1 receiver

Supply period365 days

FreeStyle Libre Sensors

ProductsFreeStyle Libre 2, 3, and 3 Plus/3+ sensors

Maximum quantity2 sensors

Supply period28 days

Guardian Sensors

ProductsGuardian Sensor 3 or 4

Maximum quantity5 sensors (1 box)

Supply period35 days

Simplera Sensors

ProductSimplera sensors

Maximum quantity5 sensors (1 box)

Supply period24 days

Document insulin dependence when required, frequent insulin adjustments, and the applicable glucose-related criterion.

Document failure of the required preferred-product trial and diabetes education when applicable.

Prior Authorization

Preferred CGM Authorization

Preferred CGM requests must meet the applicable criteria for the requested product. Approve Freestyle Libre products at the NDC level using NDC List AZ MFR3; members established on an integrated closed-loop insulin pump system may have the current CGM product approved.

A member changing CGM devices after starting an integrated closed-loop insulin pump system requires a new PA.
Preferred-product approval is handled at the NDC level.

Unsupported block type: billing_rule

Step Therapy

Freestyle Libre First-Line Step Therapy

Freestyle Libre is the required first-line preferred-product trial before requesting another CGM product, unless an applicable exception applies. Document that the member tried and failed the Freestyle Libre system before seeking a nonpreferred CGM.

Use the applicable AHCCCS health plan’s preferred-product requirements.
Include the failed trial in the PA submission.

Note

Health-Plan Preferred Products

Identify the member’s AHCCCS health plan and use its preferred CGM step-therapy requirements. Preferred products generally include Freestyle Libre 2 and 3; some plans also identify Dexcom G6 and G7 as preferred.

Arizona Complete Health: Freestyle Libre 2 and 3.
Banner University: Freestyle Libre 2 and 3.
Family Care: Freestyle Libre 2 and 3.
Care 1st Health Plan DCS Comprehensive: Freestyle Libre 2 and 3; Dexcom G6 and G7.
AHCCCS Fee-for-Service and other listed plans: verify the plan-specific preferred-product requirements before submission.

Documentation Required

Document Preferred-Product Trial Failure

When requesting a nonpreferred product, submit chart notes or laboratory results documenting the member’s failed trial of the applicable preferred product. The record should explain the trial and why it was unsuccessful.

Document the Freestyle Libre trial failure unless the applicable health plan identifies a different preferred-product sequence.
A nonpreferred request without this documentation is at risk for denial.

Documentation Required

Clinical Supporting Records

Submit clinical records supporting the medical need for the CGM. Records should document frequent insulin adjustments based on blood glucose or CGM results and the qualifying glucose-related condition or diagnosis.

Qualifying conditions may include Type I or Type II diabetes, gestational diabetes, hypoglycemia unawareness, postprandial hyperglycemia, or recurrent diabetic ketoacidosis.
A 72-hour short-term CGM use request may be submitted to determine baseline insulin levels before insulin pump initiation.
For nonpreferred requests, supporting documentation is specifically required for applicable diagnoses and frequent insulin adjustments.

Documentation Required

Verify Insulin Dependence

Verify insulin dependence using paid insulin claims from the previous 60 days when the criterion applies. For Freestyle Libre, qualifying insulin paid claims may be confirmed in the member’s PBM profile and can allow adjudication without a PA submission.

Nonpreferred requests require insulin dependence demonstrated by paid claims within the past 60 days when using the diabetes-and-insulin criterion.
Retain or submit supporting verification as required by the PA process.

Documentation Required

Document Hypoglycemia

Submit chart documentation supporting frequent hypoglycemic episodes when using hypoglycemia as the qualifying clinical criterion. Hypoglycemia unawareness and other hypoglycemia-related diagnoses also require supporting medical records for nonpreferred requests.

Document the frequency and clinical circumstances of episodes.
Hypoglycemia unawareness must be supported by the member’s medical record.

Documentation Required

Diabetes Education Attestation

The provider must attest that the member is enrolled in or has completed a comprehensive diabetes education program. Include the attestation with the authorization request when required.

The education requirement applies to the applicable initial-authorization criteria.
Failure to provide the attestation may prevent approval.

Prior Authorization

Reauthorization Adherence and Data Sharing

For reauthorization, show that the member is using the same CGM device regularly through claims history and provider chart notes. The member must also share device readings with a physician or other healthcare professional for review as part of diabetes management.

Submit claims-history and chart-note evidence of regular use.
Document required sharing of CGM readings with the treating clinician.

Billing Rule

Claim-Processing Verification

After PA approval, complete claim-processing verification by setting both required flags to Y and running a trial claim. Confirm that the claim adjudicates and pays with the PA in place.

Third Party Exception Flag = Y.
Medicaid Product Flag = Y.
Run the trial claim before relying on the authorization for payment.
Preferred products are approved at NDC level; nonpreferred products are approved at GPI level using GPI List AZMCGMNP.

Denial Risk

Nonpreferred Product Without Preferred-Product Failure

A request for a nonpreferred CGM is at risk for denial when the required failed preferred-product trial is not documented. Submit the applicable chart notes or laboratory results before requesting a nonpreferred product.

Document failure of Freestyle Libre or the health plan’s designated preferred product.
Do not rely solely on a stated preference for the nonpreferred device.

Denial Risk

Insufficient Clinical-Need Documentation

A request is at risk for denial when the record does not establish insulin dependence or another qualifying clinical need. Ensure the submission supports the applicable diagnosis, insulin claims, glucose-related condition, and frequent insulin adjustments when required.

Verify insulin paid claims within the previous 60 days when required.
Provide supporting documentation for frequent insulin adjustments.
Provide evidence of qualifying conditions such as elevated hemoglobin A1c, frequent hypoglycemia, gestational diabetes, hypoglycemia unawareness, postprandial hyperglycemia, or recurrent diabetic ketoacidosis.

Denial Risk

Age or Education Requirement Not Met

Approval may be denied when the member does not meet the FDA-approved age for the requested product or when the provider does not attest to enrollment in or completion of comprehensive diabetes education.

New products must not be approved below their FDA-approved age.
Include the required diabetes-education attestation.

Denial Risk

Excess Quantity Request

Additional transmitter or sensor quantities are generally denied unless the request is for a vacation override and the member is adherent to using the device. Requests not qualifying for the override should be denied under the quantity-limit guideline.

Document the vacation override when applicable.
Document member adherence to device use.
Use product-specific denial language when the override requirements are not met.

Denial Risk

Product-Specific Quantity Limits

Requests exceeding product-specific quantity limits are at risk for denial. Apply the applicable limits for transmitters, receivers, and sensors and use the manufacturer’s replacement process for defective products.

Dexcom G6 or G7 transmitter: maximum 1 per 90 days.
Dexcom G6 or G7 sensors: maximum 3 per 30 days.
Dexcom G6 receiver: maximum 1 per 365 days.
FreeStyle Libre 2, 3, or 3 Plus/3+ sensors: maximum 2 per 28 days.
Guardian Sensor 3 or 4: maximum 5 sensors per 35 days.
Simplera sensors: maximum 5 sensors per 24 days.

Denial Risk

Failure to Meet General Coverage Requirements

Services that are not medically necessary, cost effective, and federally or state reimbursable are not covered. Coverage remains subject to these general requirements in addition to the CGM-specific criteria and limitations.

All applicable medical-necessity and program-reimbursement requirements must be satisfied.
PA approval does not override general coverage requirements.