Prior authorization rules (who needs PA and recent PA changes)

Prior authorization requirements vary by product and member type: Medicare Advantage requires PA only for non-Abbott branded home blood glucose monitors; effective 10/1/2025 Dexcom and Abbott FreeStyle Libre non‑implantable CGMs obtained from a retail pharmacy do not require PA (self‑funded commercial products may still require PBM PA); effective 3/1/2026 PA is no longer required for ICGM in Medicare Advantage and is no longer recommended for Commercial products.

• Medicare Advantage: PA required only for non‑Abbott branded home blood glucose monitors. Contact BCBSRI PBM at 1‑800‑693‑6651, fax 855‑212‑8110, or covermymeds.com to submit requests.
• Effective 10/1/2025: retail pharmacy‑sourced Dexcom and Abbott FreeStyle Libre non‑implantable CGMs do not require PA; DME‑sourced Dexcom/Libre and FDA‑approved non‑implantable CGMs also do not require PA.
• Effective 3/1/2026: PA removed for implantable CGMs (Medicare Advantage) and PA no longer recommended for Commercial products.

Prior authorization requirements — Medicare Advantage vs Commercial

Medicare Advantage and Commercial coverage differ: Medicare‑approved non‑implantable CGMs do not require prior authorization and may be obtained via DME or Pharmacy; commercial retail Dexcom and FreeStyle Libre obtained through pharmacy no longer require PA effective 10/1/2025, but self‑funded commercial plans may still require PBM prior authorization.

• Medicare Advantage: Medicare‑approved CGMs do not require prior authorization and can be supplied via DME or pharmacy.
• Commercial: retail Dexcom/FreeStyle Libre through BCBSRI PBM — no PA effective 10/1/2025; self‑funded commercial products may still require PBM PA.
• DME‑sourced non‑implantable CGMs do not require prior authorization and are covered under the DME benefit.

Prior authorization: legacy device transition — document discontinued models

When transitioning patients from legacy devices, document device model and note discontinued support; Dexcom G4/G5 sales and software support ceased in 2020 and providers should expect to transition to currently supported systems when requesting coverage.

• Document current device model and that the legacy model (e.g., Dexcom G4 Platinum, G5 Mobile) is discontinued and no longer supported.
• Expect transition to newer systems (e.g., Dexcom G6/G7) when requesting coverage or replacement supplies.

Prior authorization for CGM devices — account for availability/support

Prior authorization processes should account for device availability and model support; the policy references discontinued CGM systems and advises documentation for appropriate device transition or replacement.

• If a requested device is discontinued (support/sales ceased), include documentation justifying use or need to transition to a supported device.
• Verify device availability when submitting authorization or coverage requests.

Prior authorization not specified in this section — follow explicit PA guidance

This section of the policy lists devices but does not state prior authorization requirements for many listed device entries; providers should follow the specific PA guidance elsewhere in the policy and PBM instructions.

• Device name lists in the document do not substitute for PA policy — use the explicit PA rules (see Medicare/Commercial and PBM guidance).
• Check member‑specific benefits for PA applicability.

Insulin‑treated status may affect coverage — definition and implications

Insulin‑treated is defined as members receiving insulin injections (oral agents do not qualify); insurer application of insulin‑treated status affects modifier use and eligibility for CGM coverage when criteria require insulin treatment.

• Definition: 'Insulin‑treated' = receiving insulin injections; oral medications alone do not qualify.
• Insulin‑treated status is used for clinical indication (one pathway for CGM) and for billing modifiers (KX vs KS).

PDAC listing and correct HCPCS billing required for coverage

Devices and supplies billed under HCPCS code E2103 must be PDAC listed to be covered; BCBSRI requires PDAC approval for devices/supplies to be considered covered and cautions against billing non‑adjunctive devices with A9276–A9278.

• Continuous glucose monitor systems not listed on the PDAC Product Classification List for HCPCS E2103 will not be covered.
• Do not file non‑adjunctive devices and associated supplies with HCPCS A9276–A9278; bill under A4239 and E2103 for non‑adjunctive devices.

Prior authorization explicitly absent in this fragment — verify elsewhere

This fragment contains no explicit PA requirements; where PA is required the policy provides specific PBM contact details — absence here means do not assume PA applies without checking policy sections and member benefit.

• If PA is not mentioned for a device in a given section, confirm PA status via PBM or provider call center before billing or dispensing.
• Do not infer authorization from device listings alone.

Step therapy / utilization management not specified — no stated step therapy

The policy notes pharmacy benefit operational changes for branded retail CGMs but does not specify any step therapy requirements in the document; no step therapy sequencing is stated for CGMs.

• Effective 10/1/2025 changes remove PBM PA for retail Dexcom and FreeStyle Libre but the policy does not establish step therapy.
• Self‑funded commercial products may still be subject to PBM PA — no step therapy language provided.

Step therapy not stated for commercial retail CGM access

Commercial members may obtain Dexcom and FreeStyle Libre through retail pharmacy or DME; the policy provides no explicit step‑therapy language or required trial of alternate CGM devices.

• Retail pharmacy and DME pathways available; no requirement to try other devices first is documented.
• No explicit commercial step therapy rules are stated for retail CGM access.

Step therapy not stated in device model listings

No explicit step therapy requirements are stated in the referenced device model chunks — the listings repeat product names without establishing utilization sequencing or step edits.

• Device model lists do not include step therapy directives.
• Follow PBM/DME PA rules where applicable rather than inferring step therapy from model listings.

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Step therapy not specified across device model chunks

Step therapy is not specified across the examined device model chunks; providers should not assume step therapy applies and must follow PBM or benefit plan rules.

• No documented requirement to try alternative glucose monitors before the requested device.
• Confirm any utilization management edits through BCBSRI PBM or provider call center.

Modifier and supply limit requirements (KX/KS and unit limits)

Modifiers KX (insulin‑treated) and KS (non‑insulin treated) must be added to HCPCS supply codes on every claim; supply unit limits (e.g., test strips/lancets) control benefit and reimbursement.

• Add KX modifier if beneficiary is insulin treated; do not use KX for members not treated with insulin.
• Add KS modifier if beneficiary is non‑insulin treated.
• Test strip/lancet limits: insulin dependent = 500 units per 3 months; non‑insulin dependent = 200 units per 3 months.

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How to submit prior authorization requests (PBM contact and pathways)

Submit prior authorization requests for PBM‑managed products to BCBSRI's Pharmacy Benefit Management Vendor: phone 1‑800‑693‑6651, fax 855‑212‑8110, or via covermymeds.com.

• Use the PBM contact for non‑Abbott home glucose monitor PA requests under Medicare Advantage and for Commercial PBM‑managed products.
• Include clinical documentation as required (see clinical documentation callout).

Clinical documentation required when ordering a CGM

For CGM ordering, document diagnosis of diabetes, that the patient/caregiver has sufficient CGM training, and that an in‑person or Medicare‑approved telehealth visit occurred within 6 months prior to ordering to evaluate diabetes control and meet indications.

• Document diabetes diagnosis and that CGM prescription aligns with FDA indications for use.
• Document patient/caregiver training on CGM use and an in‑person or Medicare‑approved telehealth visit within 6 months prior to ordering to evaluate control and indications.

Document device model and availability (note discontinued models)

Document the exact device model and whether the model is discontinued or being transitioned (for example note Dexcom G4/G5 discontinued and support ceased in 2020) to support coverage decisions and necessary transitions to currently supported devices.

• Record device make/model and manufacturer support/sale status when relevant.
• If the existing device is discontinued, document the need and plan to transition to a supported device.

Document device model and patient age/labeling

Include device model and intended patient age in documentation; manufacturer age indications (e.g., devices indicated for ≥2 years or ≥18 years) and sensor wear durations should be recorded to confirm suitability.

• Document manufacturer age indications (examples: ≥2 years for several Dexcom/FreeStyle Libre systems; ≥18 years for some OTC devices).
• Record sensor wear duration per device labeling (examples: up to 7 days for older models; 10–365 days for various systems).

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Document device indications and age in clinical record

Document device indications and manufacturer age labeling when ordering (e.g., some Dexcom and FreeStyle Libre systems are indicated for children ≥2 years; others for adults ≥18 years).

• Include the device's intended use and age indication in the patient record to support medical necessity.
• Use manufacturer labeling to confirm whether the device can replace fingerstick testing for treatment decisions.

Include HCPCS and NDC on claims for device dispensed

Claims for devices and supplies must include the HCPCS code and the NDC for the device dispensed to ensure correct processing.

• File claims with both the HCPCS code (e.g., A4239, E2103) and the NDC of the dispensed device.
• Do not bill non‑adjunctive devices under A9276–A9278; use A4239/E2103 for non‑adjunctive CGMs.

Modifier requirements for claims (KX vs KS)

CMS‑required modifiers must be added to HCPCS supply codes: use KX for insulin‑treated members and KS for non‑insulin treated members; incorrect modifier use may affect reimbursement.

• KX modifier required for insulin‑treated beneficiaries; do not use KX for members not treated with insulin.
• KS modifier required for non‑insulin treated beneficiaries.

Check member benefits and eligibility prior to ordering

Check member benefits and eligibility with the provider call center before furnishing devices or supplies; benefits and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement and supersede this policy.

• Call the provider call center for member‑specific benefit information.
• Do not assume coverage — verify eligibility and benefit limitations prior to ordering or billing.

PA required for non‑Abbott home glucose monitors (Medicare Advantage) — denial risk if not obtained

Medicare Advantage requires prior authorization for non‑Abbott home glucose monitors; failure to obtain PA for these products may lead to claim denial.

• Obtain PA via BCBSRI PBM for non‑Abbott home blood glucose monitors under Medicare Advantage.
• Failure to secure required PA may result in denial for those products.

Audit and documentation risk — keep records available for BCBSRI review

BCBSRI may audit services and request documentation; failure to provide requested records may result in denial or retraction of payment.

• Maintain documentation (training, visit notes, device model, age indications) available for BCBSRI upon request.
• Failure to produce requested information may lead to denial or retraction of payment.

Not covered supply items (A9270, A9275, A4244–A4247, A4250) — will be denied

Certain supply items and codes are not covered and will be denied if billed: A9270 (glucose monitors not designed for home use), A9275 (home blood glucose disposable monitor including test strips), A4244/A4245 (alcohol/peroxide), A4246/A4247 (betadine/phisoHex), and A4250 (urine test reagent strips) when used with a CGM.

• Do not bill covered benefits for A9270 or A9275 — these will be denied as not covered.
• Do not bill cleansing agents coded A4244–A4247 or urine reagent strips A4250 for use with CGM; they are not covered.

Legacy device discontinuation may affect coverage (Dexcom G4/G5)

Claims or requests involving Dexcom G4 Platinum and G5 Mobile systems may be affected because Dexcom stopped selling these models and ceased support/software in 2020; providers should document the need to transition to supported systems.

• Document if a member is using a discontinued model and justify transition to a supported device.
• Expect denials or coverage issues if attempting to obtain supplies/support for discontinued devices.

Discontinued device support — cite discontinued models in documentation

Sales and support for some legacy devices (Dexcom G4/G5) ceased in 2020; use of discontinued devices may be problematic for coverage and replacement.

• Note discontinued device support in the clinical record when relevant.
• Plan transition to current, supported models for ongoing coverage.

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Insulin‑treated definition noted — document insulin injections when required

The policy clarifies that 'insulin‑treated' means receiving insulin injections (oral therapies do not qualify); coverage that requires insulin treatment may be denied if the member is not insulin‑treated.

• If coverage criteria require the member to be insulin‑treated, document insulin injections in the medical record.
• Oral antidiabetic medications alone do not meet the insulin‑treated definition.

PDAC listing required for E2103 coverage

PDAC review/listing is required for devices/supplies billed to E2103; devices not reviewed and listed on the PDAC Product Classification List for E2103 will not be covered.

• Confirm PDAC listing for a device before billing under HCPCS E2103.
• Devices/supplies without PDAC listing for E2103 are not eligible for coverage.

Incorrect HCPCS billing risk (A9276–A9278 vs A4239/E2103)

Incorrect HCPCS billing (e.g., using A9276–A9278 for non‑adjunctive CGM devices/supplies) is considered incorrect filing and may cause claim processing errors or denial; BCBSRI requires billing non‑adjunctive devices under A4239 and E2103.

• Do not bill non‑adjunctive devices and supplies with A9276–A9278; use A4239 (supply) and E2103 (device) for non‑adjunctive CGMs.
• Incorrect HCPCS use may result in denial or processing issues.

Member financial liability when services are non‑covered — written consent needed to bill member

If services are determined to be not medically necessary or are non‑covered benefits, the member may not be charged unless the member is informed in writing and agrees in advance to pay; benefits and eligibility are controlled by subscriber/employer documents.

• Verify coverage prior to providing services and obtain written member agreement before billing the member for non‑covered services.
• Benefits and eligibility in subscriber documents supersede policy.