Blue Cross Blue Shield RI continuous CGM Coverage

Coverage criteria for continuous glucose monitoring

Covered Indications

Covered when device meets payer and CMS definitions for therapeutic use and product type:

Therapeutic CGM coverage (Medicare): Device must meet CMS definition of 'therapeutic' CGM (usable for making treatment decisions without confirmatory fingerstick) as described in CMS Ruling 1682R and Medicare guidance; therapeutic CGMs are covered under the DME benefit.

Claims for blood glucose monitoring (BGM) and related supplies billed in addition to an approved therapeutic CGM device and associated supply allowance will be denied as not covered.

Commercial product coverage: Continuous glucose monitoring is a covered service under Commercial products when billed with the listed HCPCS codes (A9276, A9277, A9278, K0553, K0554, S1030, S1031) as appropriate to the product.

A 90-day supply of HCPCS code K0553 may be billed where applicable.

Not Medically Necessary / Not Covered

Not covered when meeting any of the following conditions:

Non-therapeutic (adjunctive) CGMs: CGMs intended as adjunctive devices (non-therapeutic) that complement but do not replace blood glucose monitor information are not covered by Medicare and will be denied as non-covered per CMS Ruling 1682R.

Non-home or non-DME monitors: Glucose monitors not designed for use in the home must be coded A9270 and will be denied as statutorily not covered (no benefit category).

Supplies not required for device function: Items not required for the proper functioning of the device (for example: alcohol/peroxide A4244, A4245; betadine/phisoHex A4246, A4247; urine test reagent strips A4250; home disposable monitors including test strips A9275) are not covered.

Certain continuous glucose monitoring (CGM) devices and related items are excluded from coverage when they are adjunctive or otherwise not intended for therapeutic, home use. Adjunctive/non-therapeutic CGMs are those that are intended to complement, not replace, information obtained from a separate blood glucose monitor and are not approved for making treatment decisions without confirmatory fingerstick testing; these devices are not covered by Medicare and will be denied as non-covered. Additionally, glucose monitors not designed for home use must be coded A9270 and will be denied as statutorily not covered.

Certain supplies that are not required for the proper functioning of a CGM are specifically excluded. Examples listed in the policy include alcohol or peroxide (A4244, A4245), betadine or phisoHex (A4246, A4247), and urine test reagent strips or tablets (A4250). The policy also notes that home blood glucose disposable monitors, including test strips (A9275), and reflectance colorimeter devices intended for clinical settings are not covered as DME for home use.

Services determined to be not medically necessary or that are non-covered benefits are excluded from coverage under this policy. Coverage and benefits are governed by the member's subscriber agreement, member certificate, and/or employer agreement, which supersede this medical policy; providers should verify member-specific eligibility and benefit details with the provider call center.

For Medicare (Blue CHiP for Medicare) the policy restates that CGMs classified as adjunctive/non-therapeutic — i.e., devices intended only to complement blood glucose monitors and not to be used alone for making treatment decisions — are considered not medically necessary for Medicare coverage and will be denied as non-covered. Therapeutic CGMs that meet the CMS definition (CMS Ruling 1682R) are the devices eligible for coverage under the DME benefit.

When a service or item is determined to be not medically necessary or otherwise non-covered, providers may not bill the member for that service unless the member has been informed in advance and has agreed in writing to accept financial responsibility. Refer to your participation agreement(s) for additional billing and collection requirements and verify member-specific benefits prior to providing services.

HCPCS and CPT coding guidance

Covered HCPCS (Medicare)HCPCSCovered

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

Not covered HCPCS (Medicare — non-therapeutic)HCPCSNot Covered

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

Covered HCPCS (Commercial products)HCPCSCovered

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
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
S1030	Continuous non-invasive glucose monitoring device, purchase
S1031	Continuous non-invasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor

Covered CPT CodesCPTCovered

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

Not Covered HCPCS/suppliesHCPCSNot Covered

A4244	Alcohol/peroxide (example) - not covered
A4245	Alcohol/peroxide (example) - 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 home use - to be coded A9270 and denied as not covered
A9275	Home blood glucose disposable monitor, including test strips - not covered

Test strips and lancets — 3-month utilization

Non-insulin-treated membersUsual utilization: up to 100 test strips and up to 100 lancets per 3 months.

Insulin-treated membersUsual utilization: up to 300 test strips and up to 300 lancets per 3 months.

Coding referencesTest strips: A4253; Lancets: A4259 — CMS MUEs and utilization guidance applied.

Provider requirements, billing, and denial risk

Prior Authorization

BlueCHiP for Medicare and Commercial Products: No prior authorization is required.

Note

Verify Benefits and Prior Authorization

Providers must verify member benefits and eligibility prior to providing services. Coverage and benefit determinations are governed by the member's subscriber agreement, member certificate, and/or employer agreement. For member-specific benefit or eligibility questions, contact the provider call center.

Documentation Required

Therapeutic Device Requirement

Medicare covers only therapeutic continuous glucose monitoring (CGM) devices per CMS Ruling 1682R. Therapeutic CGMs provide information that can be used to make diabetes treatment decisions (for example, changing diet or insulin dosage) based solely on CGM readings. CGMs that are adjunctive/non-therapeutic (used to complement, not replace, blood glucose monitors) are not covered.

Key definitions

Therapeutic CGM (definition)

DefinitionTherapeutic CGM: a device that provides information that can be used to make diabetes treatment decisions (e.g., change diet or insulin dosage) based solely on CGM readings and is intended to replace information obtained from blood glucose monitors.

Medicare implicationCovered by BlueCHiP for Medicare when meeting CMS definition (CMS Ruling 1682R).

Coverage consequenceClaims for blood glucose meters and related supplies billed in addition to an approved therapeutic CGM will be denied as not covered.

Non-therapeutic (adjunctive) CGM (definition and coverage)

DefinitionNon-therapeutic (adjunctive) CGM: a CGM intended to complement, not replace, information obtained from a separate blood glucose monitor and not used alone to make diabetes treatment decisions.

Medicare implication

Background on continuous glucose monitoring

Continuous glucose monitoring (CGM) systems measure interstitial glucose at regular intervals to show glucose trends and patterns over time. Some CGMs are designated as therapeutic — providing readings intended to be used alone for diabetes treatment decisions (for example, altering insulin dosing or diet) — while others are adjunctive/non-therapeutic and intended only to supplement fingerstick blood glucose measurements. Device design and intended use (including suitability for home use) determine whether a device qualifies for coverage; adjunctive devices and monitors not designed for home use are excluded from Medicare coverage.

OpenPayer

Glucose Monitoring — Continuous

Coverage criteria for continuous glucose monitoring

HCPCS and CPT coding guidance

Provider requirements, billing, and denial risk

Key definitions

Background on continuous glucose monitoring