CurrentAvMedPolicy N/A

Continuous Glucose Monitor (CGM) prior authorization

Provides prior authorization and step-edit request requirements for coverage of continuous glucose monitor devices and supplies for AvMed members; applies to prescribing providers requesting CGM devices (formulary and non-formulary).

Policy Summary

PayerAvMed

PolicyContinuous Glucose Monitor (CGM) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization using the PA form with signed prescriber name and complete supporting documentation (labs, diagnostics, chart notes) to request CGM devices and supplies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsLong-term authorization

1 monthShort-term authorization

1/365dReceiver limit

3/30d10-day sensors

Coverage Criteria for Continuous Glucose Monitors

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Short-term CGM (30 days)

Covered when ALL of the following are met for Short-term CGM

Short-term CGM criteria

Diagnosis of ONE of: Type 1 Diabetes Mellitus; Type 2 Diabetes Mellitus; Gestational Diabetes
Clinical indications: Member must demonstrate at least ONE of: dawn phenomenon; hypoglycemia unawareness; nocturnal hypoglycemia; postprandial hyperglycemia; significant change to diabetes treatment regimen (e.g., initiation of insulin or change to pump therapy); unexplained hyperglycemia; or requires short-term blood glucose monitoring (7-14 days).

Replacement Device

Replacement device authorization

Replacement device criteria: Member previously approved for a CGM and at least ONE device problem limiting use

Provider or member must submit documentation that current CGM is not under warranty, including date of warranty expiration; examples of problems include abuse/misuse, reagent or instrument failure/defective devices, defects in product design, product instability, failure to perform per package insert, incorrect test results, unexplained QC failures, or other device problems that may compromise patient safety.

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required — PA is required for Continuous Glucose Monitors (CGM) and related supplies. One prior authorization form may be submitted to request any formulary or non‑formulary CGM; if approved, corresponding supplies (readers, sensors, transmitters) will be authorized automatically.

One PA form may cover a single requested CGM and its supplies
Fax completed form to 1-305-671-0200 as applicable

Step Therapy

Non‑formulary Medical Exception / Step‑Edit

Non‑formulary CGM requests require a Pharmacy Medical Necessity Request Form (medical exception). Previous therapies will be verified via pharmacy paid claims or submitted chart notes. Use of samples to initiate therapy does not meet step‑edit/preauthorization criteria.

Submit Pharmacy Medical Necessity Request Form for non‑formulary CGMs (e.g., Eversense, Guardian 3/4)
Documentation must justify medical necessity versus formulary options listed

Documentation Required

Required Submission Documentation

Required submission documentation includes prescriber signature (hand‑signed; preprinted stamps not valid), prescriber and member information, diagnosis and ICD code(s), and supporting documentation such as lab results, diagnostics, and chart notes. Incomplete, incorrect, or illegible submissions — including missing supporting labs/diagnostics — may delay or result in denial of the authorization request.

Prescriber must sign and clearly print name on the request form (no preprinted stamps)
Include member/prescriber contact info, diagnosis, ICD‑10 code(s), and all supporting clinical documentation
Missing or illegible information may delay processing; inadequate documentation may lead to denial

Denial Risk

Incomplete or Illegible Submission

If the information provided on the prior authorization form is incomplete, incorrect, or illegible, the authorization process can be delayed. Ensure all fields are complete and legible and that required attachments (labs, diagnostics, chart notes) are included to avoid processing delays.

Incomplete/illegible forms will delay authorization
Attach all requested labs/diagnostics and chart notes to support each checked clinical criterion

Background

Continuous glucose monitors (CGMs) are systems used for ongoing glucose monitoring in patients with diabetes and include interchangeable components such as sensors, transmitters, and readers/receivers. Sensors measure interstitial glucose levels, transmitters send sensor data to a display device or smartphone, and readers/receivers present glucose values and trends to patients and clinicians.

This policy differentiates long-term CGM use (authorized for 12 months) for members who require chronic insulin therapy (at least one daily insulin injection or insulin pump use) from short-term CGM monitoring (authorized for 30 days) for temporary diagnostic or monitoring indications (for example, evaluation of dawn phenomenon, hypoglycemia unawareness, nocturnal hypoglycemia, postprandial hyperglycemia, significant regimen change, unexplained hyperglycemia, or other short-term monitoring needs).

Replacement device requests are handled separately and require documentation that the member was previously approved for a CGM and that device problems limiting use have occurred; warranty status and supporting documentation must be provided for replacement approvals.

Definitions

Long-term vs Short-term CGM

Long-term CGM (authorization length)12 months

Long-term CGM (definition)Chronic use when member requires at least one daily insulin injection or current use of an insulin pump

Short-term CGM (authorization length)1 month (30 days)

Short-term CGM (definition)Temporary monitoring (e.g., 7-14 days) for specific clinical indications such as dawn phenomenon, hypoglycemia unawareness, nocturnal hypoglycemia, postprandial hyperglycemia, significant regimen changes, unexplained hyperglycemia, or other short-term monitoring needs

Initial Therapy Criteria

Short-term initial therapy

Short-term initial use: Initial short-term CGM covered when patient has a diagnosis of diabetes and demonstrates at least ONE specified clinical indication or requires short-term monitoring30 days

Intended monitoring periods such as 7-14 days; length of authorization: 1 month (30 days).

Continuation and Replacement Criteria

Continuation / Replacement

Continuation/Replacement: If member will discontinue a previously prescribed CGM upon approval, provider must list device/supplies discontinued and initiated with effective dates; for replacement, member must have had prior approval and demonstrate device problems; document warranty status

Provide documentation on the drug information section of the request (medications discontinued/initiated with effective dates). For replacement devices, submit evidence current device is not under warranty including warranty expiration date and describe device problem(s) such as misuse, failure/defect, incorrect test results, QC failures, design defects, product instability, or other issues.

Step Therapy and Medical Exception

Requirement	Details
Non-formulary CGM requests	Medical exception required via submission of the Pharmacy Medical Necessity Request Form for all non‑formulary CGM products (examples listed: Eversense, Guardian 3, Guardian 4).
Single prior authorization form	Only one PA form is required for the request of any formulary or non‑formulary CGM; if approved, authorization will include corresponding supplies (readers, sensors, transmitters).
Verification of prior therapies	Previous therapies will be verified through pharmacy paid claims or submitted chart notes as part of the medical exception/step‑edit review.
Samples	Use of samples to initiate therapy does not meet step‑edit/preauthorization criteria.