CurrentAspirus ArisePolicy N/A

Coverage criteria for non-preferred continuous glucose monitors (CGMs) and glucose testing supplies

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Covers authorization and criteria for non-preferred continuous glucose monitors (CGMs) and non-preferred glucose testing supplies for members with diabetes; applies to Aspirus Arise members and providers ordering these products.

Policy Summary

PayerAspirus Arise

PolicyCoverage criteria for non-preferred CGMs and testing supplies

Policy CodePolicy N/A

Change TypeOperational updatesadded and revised targeted product lists

Effective Date

Last ReviewSep 22, 2025

Next Review DateJun 16, 2025

Key ActionObtain prior authorization documenting prior trials of both formulary CGMs (Dexcom and Freestyle Libre) or provide clinical rationale for inability to use formulary products.

SourceLink

POLICY UPDATE CHANGES

Added Simplera and Enlite to the Targeted Products list.

Updated Targeted Products list for testing supplies to include Accu-Chek Smartview and Accu-Chek Aviva Plus and removed Accu-Chek Test Strips.

1 yearcoverage duration for CGMs

1 year

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CurrentAspirus ArisePolicy N/A

Coverage criteria for non-preferred continuous glucose monitors (CGMs) and glucose testing supplies

Customize your policy alerts

Sign up for all Aspirus Arise policy alerts

Know when Aspirus Arise releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerAspirus Arise

PolicyCoverage criteria for non-preferred CGMs and testing supplies

Policy CodePolicy N/A

Change TypeOperational updatesadded and revised targeted product lists

Effective Date

Last ReviewSep 22, 2025

Next Review DateJun 16, 2025

Key ActionObtain prior authorization documenting prior trials of both formulary CGMs (Dexcom and Freestyle Libre) or provide clinical rationale for inability to use formulary products.

SourceLink

POLICY UPDATE CHANGES

Added Simplera and Enlite to the Targeted Products list.

Updated Targeted Products list for testing supplies to include Accu-Chek Smartview and Accu-Chek Aviva Plus and removed Accu-Chek Test Strips.

1 yearcoverage duration for CGMs

1 year

Coverage Criteria for Targeted CGMs and Non-Preferred Testing Supplies

Initial Therapy

Approve initial targeted CGM requests when ALL of the following are met:

Initial CGM approval: 1. Has diabetes mellitus

Formulary trial or clinical reason: 2. Has tried and had an inadequate experience with both formulary continuous glucose monitor (CGM) systems (Dexcom and Freestyle Libre), or there is a clinical reason all of the formulary CGMs cannot be used

Insulin use or hypoglycemia: 3. The member is treated with insulin at least once per day OR has a history of problematic hypoglycemia with documentation of either recurrent level 2 hypoglycemic events (glucose <54 mg/dL) despite >=2 attempts to adjust medications/plan, OR a history of one level 3 hypoglycemic event requiring third-party assistance

Training: 4. The member (or the member's caregiver) has been properly trained on using the requested CGM as evidenced by the treating practitioner providing a prescription

FDA indicated use: 5. The CGM is prescribed according to its Food and Drug Administration (FDA) indicated use

Recent visit: 6. The prescriber has had an in-person visit or approved telehealth visit with the member within the past six months before ordering the CGM to evaluate diabetes control6 months

Continuation Therapy

Approve continuation of targeted CGM when ALL of the following are met:

Continuation - diabetes: 1. Has diabetes mellitus

Follow-up visits: 3. The treating practitioner conducts an in-person or Medicare-approved telehealth visit with the member to document adherence to the CGM regimen and diabetes treatment plan every six months following the initial prescriptionevery 6 months

Non-Preferred Testing Supply Approval

Approve non-preferred testing supplies when the prescriber documents training and ONE of the following:

Pump requirement: 1. Is using an insulin pump that requires the requested testing supply product for optimal benefit

Prior trials of alternatives: 2. Has tried at least two formulary alternative testing supply products (if two unique testing supply products are available), AND the previously tried formulary alternative testing supply products were ineffective

Formulary less effective or harmful: 3. The formulary testing supply products are expected to be less effective than the nonformulary testing supply products, OR the formulary products would be likely to cause harm to the patient

Severe visual impairment: 4. The member has severe visual impairment AND is requesting a meter with audio capabilities

Examples of audio meters are listed in policy

This policy does not list any exclusion criteria for continuous glucose monitors (CGMs) or blood glucose testing supplies. No member categories or clinical scenarios are explicitly excluded from consideration under this coverage policy.

Provider Requirements and Prior Authorization

Prior Authorization

Prior authorization required for targeted CGMs

Initial and continuation requests for targeted (non-preferred) continuous glucose monitors (CGMs) must be submitted with prior authorization documentation that the member meets all coverage criteria, including diabetes diagnosis, prior trials of formulary CGMs or a clinical rationale for not using formulary products, insulin use or problematic hypoglycemia, training, FDA-indicated use, and a recent visit within six months.

Prior Authorization

Prior authorization required for non-preferred testing supplies

Approval for non-preferred glucose testing supplies requires prior authorization showing the prescriber has confirmed the member received sufficient training on the requested device and that one of the policy-justified reasons (pump requirement, prior ineffective trials of formulary alternatives, expected greater effectiveness or risk from formulary products, severe visual impairment requiring audio meter, or manual dexterity impairment) is met.

Clinical Definitions

Recurrent level 2 hypoglycemic events — definition and evidentiary threshold

DefinitionRecurrent level 2 hypoglycemic events: plasma glucose <54 mg/dL (3.0 mmol/L) that persist despite multiple (>=2) attempts to adjust medication(s) and/or modify the diabetes treatment plan.

Context for ApprovalDocumentation of recurrent level 2 events can satisfy the criterion for CGM approval when problems persist despite attempts to adjust therapy.

Required evidenceClinical record showing repeated glucose measurements <54 mg/dL and notes describing >=2 therapeutic adjustments attempted with ongoing events.

Level 3 hypoglycemic event — definition and required documentation

DefinitionLevel 3 hypoglycemic event: plasma glucose <54 mg/dL (3.0 mmol/L) accompanied by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia.

Context for Approval

Background and Purpose

Continuous glucose monitors (CGMs) and blood glucose testing supplies are used to manage diabetes and improve glucose monitoring. Per policy, authorization is required for targeted non-preferred CGMs and non-preferred testing supplies; requests must document that the member meets clinical criteria and that formulary alternatives have been tried and were inadequate or are clinically unsuitable. For non-preferred testing supplies the prescriber must document that the member has received training on the requested device and provide one of the specified justifications (for example, insulin pump requirement, prior unsuccessful trials of formulary alternatives, expected greater effectiveness or risk of harm from formulary products, severe visual impairment requiring an audio meter, or manual dexterity impairment).