Glucose Monitoring (Continuous Glucose Monitoring — Implantable and Non-Implantable)
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Coverage guidelines for implantable and non-implantable continuous glucose monitoring devices for Medicare Advantage and Commercial products; home blood glucose monitors are excluded and referenced in related policies.
Effective 3/1/2026, prior authorization is no longer required for Medicare Advantage Plans for use of implantable continuous glucose monitors (ICGM).
Effective 3/1/2026, prior authorization is no longer recommended for Commercial Products for use of ICGM.
Effective 10/1/2025, Dexcom and Abbott FreeStyle Libre non-implantable CGM devices obtained from a retail pharmacy no longer require prior authorization and will be covered through the pharmacy benefit.
Coverage Criteria
Covered Services
Covered when device type and acquisition meet benefit rules:
Prior authorization removed for Medicare Advantage as of 3/1/2026; not recommended for Commercial as of 3/1/2026 (see prior authorization guidance).
Self-funded commercial products may still require prior authorization through the PBM.
Medicare Advantage CGM Coverage Criteria
A CGM may be prescribed for Medicare Advantage members when any ONE of the following indications is met and the practitioner has completed an in-person or approved telehealth visit within 6 months:
Visit requirement: Within six (6) months prior to ordering the CGM the treating practitioner must have an in-person or Medicare‑approved telehealth visit to evaluate diabetes control and determine that criteria are met.
Implantable CGM (I-CGM) Coverage
Covered when device and procedure are FDA-approved and billed with the appropriate CPT codes:
0446T includes creation of subcutaneous pocket with insertion, system activation, and patient training; policy is product-agnostic.
The policy excludes a set of consumables and devices that are not necessary for CGM function or do not meet DME/home-use definitions. Specifically, alcohol/peroxide (A4244, A4245) and betadine/phisoHex (A4246, A4247) are not covered. Urine test reagent strips (A4250) used in conjunction with a CGM are not covered. Reflectance colorimeter devices intended for clinical settings are excluded from home DME coverage due to professional recalibration requirements. Additionally, devices that do not meet the home-use definition — including glucose monitors coded A9270 and home disposable glucose monitors including test strips (A9275) — are not covered.
Non‑implantable CGM devices classified as non‑adjunctive must be billed with HCPCS A4239 (monthly supply) and E2103 (device/receiver); BCBSRI permits billing up to a 90‑day supply for A4239. Devices and supplies must be listed on the PDAC Product Classification List for HCPCS E2103 to be considered covered. Per CMS guidance, HCPCS codes A9276–A9278 (sensor, transmitter, receiver billed as A9-series supplies) are not covered for Medicare Advantage; these codes are used for Commercial billing only and should not be used to bill for the non‑adjunctive devices listed.
Services or items determined to be not medically necessary or that are identified as non‑covered benefits are excluded from coverage and may result in claim denial. Providers must verify member-specific benefits and eligibility prior to providing services and must obtain advance written member consent if the provider intends to proceed with non‑covered services at the member's expense.
Glucose monitoring devices that are not designed for use in the home must be coded as A9270 and will be denied because they are statutorily not a covered benefit under this policy.
Consistent with CMS guidance, HCPCS codes A9276–A9278 (invasive sensor, external transmitter, and external receiver billed as supply items) are not covered for Medicare Advantage. These codes may be allowable under Commercial products but must not be used when billing Medicare Advantage members.
The policy reiterates that any service determined to be not medically necessary or otherwise a non‑covered benefit is excluded from coverage and may lead to denial or member financial liability if provided without appropriate authorization and written member agreement.
Coding and Supplies
| A4244 | Alcohol (not covered) |
| A4245 | Peroxide (not covered) |
| A4246 | Betadine (not covered) |
| A4247 | PhisoHex (not covered) |
| A4250 | Urine test reagent strips or tablets (not covered when used with CGM) |
| A9270 | Glucose monitors not designed for home use (not covered) |
| A9275 | Home blood glucose disposable monitor, including test strips (not covered) |
| A9276 | Sensor; invasive (e.g., subcutaneous), disposable, for use with non-durable medical equipment interstitial continuous glucose monitoring system, one unit = 1 day supply |
| A9277 | Transmitter; external, for use with non-durable medical equipment interstitial continuous glucose monitoring system |
| A9278 | Receiver (monitor); external, for use with non-durable medical equipment interstitial continuous glucose monitoring system |
| S1030 | Continuous non-invasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code) |
| S1031 | Continuous non-invasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code) |
| 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 |
| 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 |
| KX | Modifier: use if the beneficiary/member is insulin treated |
| KS | Modifier: use if the beneficiary/member is non-insulin treated |
| affected codes | Policy references coding/payment guidelines and modifiers; specific CPT/HCPCS codes are addressed in related coding guidance and LCD/LCA documents. |
Provider Actions & Billing Guidance
Prior authorization varies by product, device, and acquisition
Prior authorization requirements depend on product and device type. Effective 3/1/2026, prior authorization is no longer required for implantable continuous glucose monitors (I-CGM) for Medicare Advantage plans and is no longer recommended for Commercial products; non-implantable CGMs do not require prior authorization for Medicare Advantage. Effective 10/1/2025, Dexcom and Abbott FreeStyle Libre non-implantable CGM devices obtained from a retail pharmacy do not require prior authorization and will be covered through the pharmacy benefit (self-funded commercial products may still require PBM prior authorization).
- I-CGM prior authorization removed for Medicare Advantage effective 3/1/2026.
- I-CGM prior authorization no longer recommended for Commercial products effective 3/1/2026.
- Non-implantable CGMs do not require prior authorization for Medicare Advantage.
- Dexcom and Abbott FreeStyle Libre obtained from retail pharmacy: prior authorization not required and covered via pharmacy benefit effective 10/1/2025; PBM prior auth may still apply for self-funded commercial plans.
Procedure coverage and billing rules for implantable and ambulatory CGM
Implantable CGM insertion and removal CPT Category III codes 0446T–0448T and ambulatory CGM professional services 95249–95251 are covered. Billing guidance notes that 0446T includes creation of subcutaneous pocket with insertion and is globally reimbursed for procedure and device; ambulatory CGM codes describe placement, calibration, training, removal, and interpretation/reporting.
- 0446T–0448T covered for implantable CGM insertion/removal (0446T includes system activation and patient training).
- 95249–95251 covered for ambulatory CGM professional services (placement, calibration, patient training, removal, and interpretation/report).
- Modifier guidance per CMS (KX/KS) applies to supply claims; global reimbursement noted for 0446T.
Use related policies and payer-specific prior authorization/coding processes
Follow related BCBSRI policies and Medicare LCD/LCA coding and payment guidelines for specific coding and reimbursement questions. Providers should use payer-specific prior authorization and billing processes and verify member eligibility before providing services.
- See related policies and Medicare Advantage National and Local Coverage Determinations for coding/payment guidance.
- File non-adjunctive devices with A4239/E2103 as required; do not bill A9276–A9278 for those non-adjunctive devices.
- Confirm member-specific benefits and prior authorization processes with BCBSRI prior to service.
Acquisition source determines benefit routing (Pharmacy vs DME)
Coverage and benefit routing depend on how non-implantable CGMs are acquired: retail pharmacy versus Durable Medical Equipment (DME). Retail pharmacy acquisition (Dexcom and Abbott FreeStyle Libre) routes coverage through the pharmacy benefit when applicable; DME acquisition is covered under the member's DME benefit without prior authorization.
- Dexcom and Abbott FreeStyle Libre obtained from retail pharmacies are covered through the pharmacy benefit (prior auth not required effective 10/1/2025).
- Devices obtained through DME are covered under the DME benefit and do not require prior authorization.
- Self-funded commercial products may still require PBM prior authorization.
Document clinical indications and patient training when ordering a CGM
Ensure the treating practitioner documents that the member meets coverage criteria when ordering a CGM and that required visits and training have occurred as specified by the policy.
- Practitioner should confirm the individual is diagnosed with diabetes and meets one of the MA indications (insulin-treated; recurrent level 2 hypoglycemia; or level 3 hypoglycemic event).
- Treating practitioner must determine the individual or caregiver has sufficient training using a CGM per FDA indications.
Make records available to BCBSRI upon request
Maintain and make available all documentation supporting the medical necessity and provision of CGM services; BCBSRI may request records at any time.
- BCBSRI may audit services provided regardless of provider participation status.
- All documentation must be available to BCBSRI upon request.
Ensure a qualifying visit within six months before ordering for MA members
For Medicare Advantage members, within six months prior to ordering a CGM the treating practitioner must have an in-person or Medicare-approved telehealth visit to evaluate diabetes control and determine that coverage criteria are met.
- Visit must occur within six (6) months prior to ordering the CGM.
- Visit may be in-person or Medicare-approved telehealth.
Verify member-specific benefits and eligibility before providing services
Verify member benefits and eligibility prior to ordering or billing; benefits and eligibility are determined by the member's subscriber agreement or employer agreement and may supersede this policy.
- Call the provider call center for member-specific benefit information.
- Confirm whether the member has pharmacy benefits through BCBSRI when routing claims for retail pharmacy-obtained devices.
Risk of denial or payment retraction if documentation is not produced
Failure to produce requested documentation upon BCBSRI audit may result in denial of the claim or retraction of payment.
- BCBSRI reserves the right to audit and request documentation regardless of provider participation status.
- Non-production of requested information can lead to denial or recoupment.
Do not bill non-covered HCPCS supply/device codes
The policy lists specific HCPCS supply and device codes that are not covered and will be denied; do not bill covered CGM services using these codes.
Confirm PDAC listing for devices billed to E2103
Continuous glucose monitor devices and supplies must be listed on the PDAC Product Classification List for HCPCS E2103 to be considered covered; devices not listed will not be covered.
Denial risk for not medically necessary or non-covered services; member billing restrictions
Services determined to be not medically necessary or that are non-covered benefits may be denied; providers may not charge members for such services unless the member was informed and provided written consent in advance.
- If services are not medically necessary or are non-covered, claims may be denied.
- Providers must obtain written member agreement in advance before charging members for non-covered services.
Background
Continuous glucose monitoring (CGM) systems measure interstitial glucose at frequent intervals and provide trend data to support diabetes management. CGM devices can be real‑time (rtCGM) or intermittently scanned (flash/isCGM) and vary in measurement frequency (typically every 1–5 minutes) and calibration requirements. CGM data can complement or replace fingerstick blood glucose monitoring depending on device designation (adjunctive vs non‑adjunctive) and specific device FDA indications, and timely CGM use supports tighter glycemic control while highlighting hypoglycemia risk.
Definitions
Revision History
Prior authorization removed for use of implantable continuous glucose monitors (I‑CGM) for Medicare Advantage plans; prior authorization is no longer recommended for Commercial products as of the same date.
Dexcom and Abbott FreeStyle Libre non‑implantable CGM devices obtained from retail pharmacies will be covered through the pharmacy benefit without prior authorization for Commercial products.
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