Blue Cross Blue Shield RI Continuous Glucose Monitor Coverage

Coverage and Medical Necessity Criteria

Implantable Continuous Glucose Monitor (Medicare Advantage)

Covered when ALL of the following are met:

I-CGM Medicare Advantage criteria: The device has United States Food and Drug Administration (FDA) approval with indications for use as a therapeutic continuous glucose monitor (CGM); and the member has diabetes mellitus; and the member is insulin-treated with multiple (three or more) daily administrations of insulin OR the member uses a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and the member's insulin treatment regimen requires frequent adjustment by the member on the basis of blood glucose monitoring (BGM) or CGM testing results; and the treating physician had an in-person visit with the member within six months prior to ordering the implantable CGM to evaluate diabetes control and determined the above criteria were met.

These conditions are all required for medical necessity under Medicare Advantage.

Implantable CGM (Commercial Products)

Commercial stance: The use of implantable continuous glucose monitor (I-CGM) devices is considered not medically necessary for commercial products because the evidence is insufficient to determine effects on health outcomes.

Commercial coverage: not medically necessary.

Non-Implantable / Therapeutic CGM Coverage

Therapeutic CGM (Medicare Advantage): Therapeutic CGMs that meet the CMS definition (provide information that can be used to make diabetes treatment decisions) are covered under Medicare Advantage; such devices may be obtained through the Durable Medical Equipment (DME) or the Pharmacy benefit and do not require prior authorization for Medicare Advantage members.

Medicare-approved therapeutic CGMs covered; non-therapeutic adjunctive devices are not covered.

Non-Implantable CGM (Commercial): Continuous glucose monitoring is a covered service for commercial products; Dexcom and Abbott FreeStyle Libre branded CGM devices are covered through the member's pharmacy benefit or may be obtained via a DME provider (authorization not required when obtained from a DME provider).

Commercial coverage available through pharmacy or DME; pharmacy-dispensed devices may require pharmacy benefit authorization per plan procedures.

Therapeutic CGM coverage

Covered when ALL of the following are met for therapeutic CGM:

Therapeutic CGM coverage: The device is a therapeutic CGM as defined by CMS (provides information to make diabetes treatment decisions and is intended to replace fingerstick testing).

Per CMS Ruling 1682R; devices that are adjunctive/non-therapeutic are not covered.

Device coding and PDAC listing: Device and associated supplies must be billed using the HCPCS codes specified for therapeutic CGM (for example K0554 and K0553) and the device must be listed on the PDAC Product Classification List for K0554 for coverage to apply.

BCBSRI requires PDAC review/listing for K0554 and discourages filing therapeutic devices under A9276/A9278.

Authorization pathway for pharmacy-dispensed devices: When Abbott FreeStyle Libre or Dexcom branded devices are obtained under the pharmacy benefit, authorization is required through BCBSRI's Pharmacy Benefit Management vendor.

Applies to pharmacy-dispensed therapeutic CGM devices; DME-obtained devices do not require authorization when covered under DME benefits.

Implantable CGM procedural coverage (Commercial)

Commercial product stance on implantable device procedures:

Implantable device procedures not medically necessary for commercial: For commercial products, code 0446T (creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and training) is considered not medically necessary. Refer to the Removal of Implantable Devices policy for guidance on code 0447T (removal) and 0448T (removal with reinsertion).

Commercial products list 0446T as not medically necessary; see related policy for 0447T/0448T.

Reflectance colorimeter devices used for measuring blood glucose in clinical settings are not covered as durable medical equipment for home use because they require frequent professional calibration and are unsuitable for home use. Urine test reagent strips (44250), when used in conjunction with a CGM, are not covered. Glucose monitors not designed for home use must be coded A9270 and will be denied as statutorily not covered. Home disposable blood glucose monitors, including test strips (49275), are not covered because they do not meet the definition of DME.

For Medicare Advantage, HCPCS codes that do not meet CMS’s definition of a therapeutic CGM are not covered. Specifically, the policy lists A9276 (sensor), A9277 (transmitter), A9278 (receiver), S1030 (purchase of continuous non‑invasive device), and S1031 (rental) as not covered when they fail to qualify as therapeutic; note that A9276 and A9277 are not used to bill supplies with K0554.

Coverage for services described in this policy is subject to the member’s subscriber agreement, member certificate, and/or employer agreement, which supersede this medical policy. Providers should verify member benefits and eligibility with BCBSRI prior to providing services. When a medically necessary service is a non‑covered benefit under a member’s plan, the member may only be billed if they have been informed in advance and have agreed in writing to accept financial responsibility.

For Commercial products, the use of implantable continuous glucose monitor devices is considered not medically necessary because the evidence is insufficient to determine the technology’s effects on health outcomes.

For Commercial products, the procedure code 0446T (creation of a subcutaneous pocket with insertion of an implantable interstitial glucose sensor, including system activation and patient training) is considered not medically necessary. The policy also references related implantable device procedure codes (0447T, 0448T) and directs providers to the Related Policy on Removal of Implantable Devices for guidance on those codes.

Coding and Supply Limits

Covered HCPCS codes (Commercial/Pharmacy context)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
A9276	Sensor; invasive (e.g., subcutaneous) disposable, for use with interstitial continuous glucose monitoring system; 1 unit = 1 supply (day)
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
S1031	Continuous non-invasive glucose monitoring device, rental, including sensor, sensor replacement; and download to monitor

Not covered for Medicare Advantage (non-therapeutic per CMS)HCPCSNot Covered

A9277	Transmitter; external, for use with interstitial continuous glucose monitoring system
A9276	Sensor; invasive subcutaneous) disposable, for use with interstitial continuous glucose monitoring system, 1 unit = 1 supply (e.g day)
A9278	Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
S1031	Continuous non-invasive glucose monitoring device, rental, including sensor, sensor replacement; and download to monitor (for physician interpretation of data, use CPT code)
S1030	Continuous non-invasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)

Ambulatory CGM CPT codesCPTCovered

95249	Ambulatory continuous glucose monitoring via subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement; hook-up, calibration of monitor; training, and printout of recording
95250	Ambulatory continuous glucose monitoring via subcutaneous sensor for a minimum of 72 hours; sensor placement; hook-up, calibration of monitor, patient removal of sensor; and training, and printout of recording
95251	Ambulatory continuous glucose monitoring via a subcutaneous sensor for minimum of 72 hours; interpretation and report

Implantable CGM CPT codesCPT

0446T	Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and training patient
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

inv-16: Insulin administration frequency — three or more daily administrations of insulin

Insulin administration frequencyThree or more daily administrations of insulin

Medicare criterion contextUsed as part of I-CGM medical necessity for Medicare Advantage (member must be insulin-treated with multiple daily injections or use a CSII pump)

Related requirementInsulin regimen must require frequent adjustment by the member based on BGM or CGM results

inv-17: Diabetic Testing Supply Limits (Test Strips & Lancets) — Insulin-dependent: 500 units per 3 months; Non-insulin-dependent: 200 units per 3 months

Insulin-dependent limit500 units per 3 months (test strips A4253)

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for implantable continuous glucose monitors for Medicare Advantage members. Providers must obtain authorization via the online tool for participating providers. For pharmacy-obtained Dexcom and Abbott FreeStyle Libre devices under commercial plans, authorization is required through BCBSRI's Pharmacy Benefit Management vendor (covermymeds.com). Dexcom and FreeStyle Libre devices obtained from a Durable Medical Equipment (DME) provider do not require prior authorization.

Medicare Advantage: prior authorization required for implantable CGMs (use online authorization tool)
Commercial (pharmacy benefit): Dexcom and Abbott FreeStyle Libre require authorization via BCBSRI PBM (covermymeds.com)
Commercial (DME purchase): Dexcom and FreeStyle Libre obtained from DME providers do not require authorization

Denial Risk

Non-therapeutic CGM Denial Risk

CGM systems that do not meet the CMS definition of a therapeutic CGM (CMS Ruling 1682R) — i.e., devices intended for adjunctive use only — will be denied as non-covered (no benefit). Claims for adjunctive/non-therapeutic CGMs that cannot support diabetes treatment decisions are not payable under Medicare Advantage.

Definitions

inv-35: Therapeutic CGM — provides glucose information usable to make treatment decisions without separate blood glucose measurements

DefinitionTherapeutic CGM: provides glucose information usable to make diabetes treatment decisions (e.g., change diet or insulin dosing) without separate blood glucose measurements

Medicare coverage stanceTherapeutic CGMs are covered under Medicare when they meet CMS definition (intend to replace fingerstick testing)

Clinical evidenceMultiple randomized trials and systematic reviews support CGM technologies for diabetes management (see references)

inv-36: Non-therapeutic (adjunctive) CGM — complements but does not replace blood glucose monitoring; may require fingerstick calibration

DefinitionNon-therapeutic (adjunctive) CGM: complements but does not replace blood glucose monitoring and is not intended as sole basis for treatment decisions; may require fingerstick calibration

Background

Continuous glucose monitors measure interstitial glucose at frequent intervals (approximately every 1–10 minutes), providing near‑real‑time glucose readings. CGMs display glucose trends, direction, and rate of change information that support glycemic management and treatment decisions. Therapeutic CGMs are intended to provide information that can be used to make diabetes treatment decisions without separate blood glucose measurements, whereas adjunctive (non‑therapeutic) CGMs are intended to complement, but not replace, fingerstick testing.

OpenPayer

Continuous Glucose Monitors (implantable and non-implantable)

Coverage and Medical Necessity Criteria

Coding and Supply Limits

Provider Actions, Authorization, and Documentation

Definitions

Background