Glucose Monitoring — Continuous
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Coverage policy for continuous (long-term) and short-term (intermittent up to 72 hours) continuous glucose monitoring devices and related supplies for BCBSRI members, distinguishing Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medicare Advantage Implantable CGM Medical Necessity
Medicare Advantage: Implantable continuous glucose monitors (I-CGM) are covered when ALL of the following are met:
Prior authorization is required for Medicare Advantage; therapeutic CGM definition per CMS Ruling 1682R determines coverage.
Product-specific coverage stance
Coverage stance differs by product:
Therapeutic versus non-therapeutic (adjunctive) distinction drives Medicare coverage.
Therapeutic CGM device and supply coverage
Covered when the device and supplies meet CMS/BCBSRI classification and PDAC listing for therapeutic CGM:
BCBSRI requires PDAC listing for coverage; filing under A9276-A9278 for these therapeutic devices is incorrect and may lead to denial.
Ambulatory CGM coverage
Ambulatory CGM monitoring is covered when procedure elements are met:
Applies to Medicare Advantage Plans and Commercial Products.
Implantable CGM procedure coverage
Implantable sensor procedures coverage stance:
Prior authorization required for implantable CGM; PDAC listing and therapeutic CGM criteria also apply.
Adjunctive or non-therapeutic CGMs are excluded from Medicare coverage because they do not meet the CMS definition of a therapeutic CGM; devices intended only to complement fingerstick testing and not to replace blood glucose monitor information are not covered (no benefit). Specific supplies that are not covered include alcohol or peroxide (A4244, A4245), betadine or phisoHex (A4246, A4247), and urine test reagent strips (A4250) because they are not required for device function. Glucose monitors not designed for home use (A9270) and home disposable blood glucose monitors including test strips (A9275) are also not covered.
When a therapeutic CGM system is billed under the appropriate HCPCS (K0554 for the dedicated receiver/device and K0553 for the supply allowance), BCBSRI allows up to a 90-day supply of K0553 to be billed. Devices and supplies must be PDAC-reviewed and listed for HCPCS code K0554 to be considered covered.
The following HCPCS/CPT codes are not considered appropriate for billing therapeutic CGM devices or associated supplies and are treated as not covered for that purpose: A9276, A9277, A9278, S1030, and S1031. These codes fail to meet the CMS definition of a therapeutic CGM and, for some devices, are explicitly not to be used to bill supplies associated with K0554.
BCBSRI requires that claims for recognized therapeutic CGM systems (for example Dexcom G5/G6 and Abbott FreeStyle Libre) and their supplies be filed using K0554 (device/receiver) and K0553 (supply allowance); filing those same systems under A9276–A9278 is considered incorrect and may result in denial.
For Commercial products, implantable continuous glucose monitoring devices are considered not medically necessary. The policy states that available evidence is insufficient to determine meaningful effects of implantable CGM technology on health outcomes, and therefore these devices are not covered under Commercial plans.
Procedural coding for implantable interstitial glucose sensor services is mixed within the document. BCBSRI identifies CPT codes 0446T, 0447T, and 0448T as the implantable sensor procedure codes. The policy instructs that claims for recognized therapeutic CGM devices and supplies must use HCPCS K0554/ K0553, and that PDAC listing for K0554 is required for device coverage.
Within the implantable procedure group, BCBSRI indicates that 0446T (creation of subcutaneous pocket with insertion) is medically necessary when the implantable CGM medical criteria are met, while 0447T and 0448T are linked to the related "Removal of Implantable Devices" policy for medical necessity determinations. Note that the document contains internal conflicting statements about medical necessity for some implantable procedure codes; providers should follow the policy requirement to meet clinical criteria and obtain prior authorization where applicable.
Coding
| K0553 | Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service |
| K0554 | Receiver (monitor), dedicated, for use with therapeutic continuous glucose monitor system |
| 0446T | Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training |
| 0447T | Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision |
| 0448T | Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation |
| A4244 | Alcohol or peroxide (not covered) |
| A4245 | Alcohol or peroxide (not covered) |
| A4246 | Betadine or phisoHex (not covered) |
| A4247 | Betadine or phisoHex (not covered) |
| A4250 | Urine test reagent strips or tablets (not covered) |
| A9270 | Glucose monitors not designed for use in the home (not covered) |
| A9275 | Home blood glucose disposable monitor, including test strips (not covered) |
| A9276 | HCPCS code sometimes used for CGM supplies (not appropriate for therapeutic devices per policy) |
| A9277 | HCPCS code sometimes used for CGM supplies (not appropriate for therapeutic devices per policy) |
| A9278 | HCPCS code sometimes used for CGM supplies (not appropriate for therapeutic devices per policy) |
| K0553 | Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service |
| K0554 | Receiver (monitor), dedicated, for use with therapeutic continuous glucose monitor system |
| A9276 | Sensor; invasive (e.g. subcutaneous) disposable, for use with interstitial continuous glucose monitoring system, 1 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 |
| S1030 | Continuous non-invasive glucose monitoring device, purchase (for physician interpretation of data) |
| S1031 | Continuous non-invasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data) |
| 95249 | Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording |
| 95250 | Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording |
| 95251 | Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; interpretation and report |
| 0446T | Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training |
| 0447T | Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision |
| 0448T | Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation |
Provider Actions & Billing Requirements
Obtain prior authorization for implantable CGM (Medicare Advantage)
Prior authorization is required for Medicare Advantage Plans for use of implantable continuous glucose monitoring (I‑CGM) and must be obtained via the online tool for participating providers.
- Prior authorization applies to implantable CGM (I‑CGM) for Medicare Advantage members.
Use the policy-specified HCPCS/CPT codes for CGM devices and procedures
File claims for therapeutic CGM devices and supplies using the HCPCS and CPT codes specified by the policy (e.g., HCPCS K0554 for the receiver and K0553 for supplies; CPT 0446T/0447T/0448T and ambulatory CGM CPTs 95249‑95251 have specific coverage conditions). Devices and supplies must meet the policy’s code-to-coverage linkage.
Apply KX/KS modifiers correctly on supply claims
Add modifier KX on HCPCS supply claims when the beneficiary is insulin treated and modifier KS when non‑insulin treated; do not use KX for beneficiaries not treated with insulin injections.
- KX = use for insulin‑treated beneficiaries.
- KS = use for non‑insulin‑treated beneficiaries.
- KX must not be used for members who are not treated with insulin injections.
Make documentation available for audits and requests
Blue Cross Blue Shield of Rhode Island may audit services and requires all documentation to be available upon request; failure to produce requested information may result in denial or retraction of payment.
Ensure an in-person visit within 6 months before ordering I‑CGM
For implantable CGM orders, the treating physician must have had an in‑person visit with the member within six months prior to ordering to evaluate diabetes control and confirm the coverage criteria are met.
Retain documentation and be prepared for BCBSRI audit requests
Maintain and be prepared to produce clinical documentation supporting medical necessity and compliance with policy requirements; BCBSRI may audit services and request documentation.
- Keep records showing diabetes diagnosis, insulin treatment details, and insulin regimen adjustments.
- Retain documentation of PDAC listing and code assignment when applicable.
Confirm PDAC listing for K0554 before billing
Ensure the CGM system is reviewed and listed by the Pricing, Data Analysis and Coding contractor (PDAC) on the Product Classification List for HCPCS code K0554; systems not PDAC‑listed for K0554 will not be covered.
Non‑therapeutic (adjunctive) CGMs will be denied
Do not expect coverage for CGM devices that are classified as non‑therapeutic (adjunctive) per CMS Ruling 1682R; such devices will be denied as statutorily not covered (no benefit).
- Non‑therapeutic (adjunctive) CGMs — those that do not replace blood glucose monitors for treatment decisions — are excluded from Medicare coverage.
File therapeutic CGM claims under K0554/K0553 — avoid A9276‑A9278
File therapeutic CGM device and supply claims under HCPCS K0554 and K0553; using codes A9276‑A9278 (or A9276/A9277/A9278/A9275) for therapeutic devices or supplies is incorrect and may lead to denial if PDAC approval is lacking or codes are misapplied.
Background
Continuous glucose monitors measure interstitial glucose at regular intervals (commonly every 1–10 minutes) to provide trend data that inform glycemic patterns. Some CGMs are used intermittently for short-term ambulatory monitoring (typically a minimum of 72 hours for ambulatory CPT codes 95249–95250 with interpretation by 95251), while other systems are intended for long-term continuous use.
A key clinical distinction in this policy is between therapeutic CGMs—which provide glucose values intended to replace fingerstick blood glucose measurements for diabetes treatment decisions—and adjunctive/non-therapeutic CGMs, which only complement fingerstick testing and are not acceptable for making treatment changes per CMS Ruling 1682R.
Definitions
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