CurrentCapital BluecrossPolicy N/A

continuous_glucose_monitor_policy

Defines prior authorization criteria for coverage of continuous glucose monitoring (CGM) systems for Capital Blue Cross members, lists preferred systems, target agents (GPI/multisource codes), clinical eligibility requirements for approval, and length of approval.

Policy Summary

PayerCapital Bluecross

Policycontinuous_glucose_monitor_policy

Policy CodePolicy N/A

Change TypeAdministrative additions / clarified

Effective Date

Next Review Date

Key ActionPrior authorization is required for non-preferred CGM products; a preferred CGM (Dexcom or FreeStyle) is required before a non-preferred CGM unless the prescriber documents failure or limitations of use of the preferred CGM.

SourceLink

POLICY UPDATE CHANGES

Multiple administrative additions over time (addition of devices such as Dexcom G7, Guardian 4, FreeStyle Libre 3 Sensor/Reader, Simplera Sync Sensor, FreeStyle Libre 2 Plus Sensor).

5Preferred CGM systems listed

12 monthsLength of approval

<54Hypoglycemia threshold (qualifying events are <54 mg/dL)

Coverage Summary

Defines prior authorization criteria for coverage of continuous glucose monitoring (CGM) systems for Capital Blue Cross members; coverage stance: covered_with_criteria. Subject: Continuous Glucose Monitor (CGM) prior authorization criteria. Status: CURRENT.

Key thresholds: approvals are granted for 12 months; qualifying hypoglycemia events are defined by a glucose threshold of less than 54 mg/dL (3.0 mmol/L); and the prescriber must document an in-person or telehealth visit within six (6) months prior to ordering (or for prior approvals a visit confirming continued adherence/use).

Preferred systems required before non-preferred CGMs include Dexcom G6, Dexcom G7, FreeStyle Libre, FreeStyle Libre 2, and FreeStyle Libre 3, unless the prescriber documents failure or limitations of the preferred device.

Policy-level thresholds

Hypoglycemia glucose thresholdglucose less than 54 mg/dL (3.0 mmol/L)

In-person/telehealth visit recencywithin six (6) months

Length of approval12 months

Preferred systems count5

Preferred systems (examples)Dexcom G6, Dexcom G7, FreeStyle Libre, FreeStyle Libre 2, FreeStyle Libre 3

Evaluation and Approval Criteria

Target CGM Agent(s) will be approved when ALL of the following are met:

ONE of the following (insulin treated OR non-insulin treated with additional requirements)

The beneficiary has diabetes mellitus AND ONE of the following (insulin treated OR non-insulin treated with additional requirements)
- The beneficiary has diabetes mellitus
- ONE of the following (insulin treated OR non-insulin treated with additional requirements)
  - A. Insulin treated: The beneficiary is insulin treated
  - B. Non-insulin treated with additional requirements
    At least ONE of the following
    i. Recurrent level 2 hypoglycemic events
    Required documentation for level 2 events
    Glucose values for qualifying events: The glucose values for the qualifying event(s) [glucose less than 54 mg/dL (3.0 mmol/L)]glucose less than 54 mg/dL (3.0 mmol/L)
    Classification as level 2: Classification of the hypoglycemic episode(s) as level 2 event(s)
    Alternative documentation for level 2: OR: Incorporate a copy of the beneficiary's BGM testing log into the medical record reflecting the specific qualifying events [glucose less than 54 mg/dL (3.0 mmol/L)]glucose less than 54 mg/dL (3.0 mmol/L)

Ongoing management / prior approval continuation

Visit documentation options
- Previously approved continuation visit: If previously approved through the plan's Prior Authorization criteria, the prescriber has indicated the beneficiary has had an in-person visit or telehealth visit to determine that the beneficiary continues to adhere to their diabetes treatment regimen and use of the CGM device
- New order visit: The prescriber has indicated the beneficiary had an in-person visit or telehealth visit to evaluate their diabetes condition within six (6) months prior to ordering the CGM and determined that criteria (1-2) above are metwithin six (6) months

Preferred device requirement or failure/limitations

ONE of the following (preferred device requirement or failure/limitations)
- Preferred CGM: The requested CGM is a preferred CGM (as determined by client)
  Preferred agents include Dexcom G6, Dexcom G7, FreeStyle Libre, FreeStyle Libre 2, and FreeStyle Libre 3
- Failure or limitations of preferred CGM: The prescriber has indicated the beneficiary has failed or has limitations of use of the preferred CGM

Approval duration: Length of Approval: 12 months12 months

Level 2 hypoglycemia: Hypoglycemia with glucose less than 54 mg/dL (3.0 mmol/L) as used in qualifying criteria; qualifying documentation may include glucose values for the events and classification of the episodes or a BGM testing log reflecting those specific events.

Level 3 hypoglycemia: Hypoglycemia characterized by altered mental and/or physical status, with qualifying glucose values less than 54 mg/dL (3.0 mmol/L), and requiring third-party assistance for treatment; documentation should include glucose values and classification of the episode and/or BGM testing log.

Codes and Product Listings

Preferred CGM agents (listed by product name)mixedCovered

Dexcom G6	Preferred CGM system
Dexcom G7	Preferred CGM system
FreeStyle Libre	Preferred CGM system
FreeStyle Libre 2	Preferred CGM system
FreeStyle Libre 3	Preferred CGM system

Target agents / detailed GPI and multisource entries (product-level identifiers)mixedCovered

97202012026200	Dexcom G6 receiver; FreeStyle Libre reader; various receivers per document
97202012066300	Dexcom G6 transmitter; Guardian Link 3 transmitter; various transmitters per document
97202012046300	Dexcom G6/G7 sensor; FreeStyle Libre sensors; Guardian sensors; Simplera Sync Sensor; other sensors per document

Other named CGM systems mentionedmixed

Minimed Enlite	Named CGM system (listed)
Minimed Guardian	Named CGM system (listed)
Guardian 4	Named CGM system (listed)
Simplera Sync Sensor	Named CGM system (listed)
FreeStyle Libre 3 Plus Sensor	Named CGM system (listed)

Actions Required from Ordering Providers

Prior Authorization

Prior authorization required for non-preferred products

PA applies to nonpreferred CGM products; a preferred CGM (Dexcom or FreeStyle) is required before a non-preferred CGM unless the prescriber documents failure or limitations of use of the preferred CGM.

Preferred CGM (Dexcom or FreeStyle) required before non-preferred unless documented failure/limitations

Documentation Required

Document hypoglycemic events and BGM logs

For eligibility based on hypoglycemia, include documentation of glucose values for qualifying events (glucose <54 mg/dL), classification of events (level 2 or level 3), and/or incorporate a copy of the beneficiary's BGM testing log reflecting the qualifying events; for level 3 events, document need for third-party assistance.

Glucose values for qualifying events: <54 mg/dL (3.0 mmol/L)
Classification of the hypoglycemic events as level 2 vs level 3
Incorporate a copy of the beneficiary's BGM testing log reflecting the qualifying events
For level 3 events: documentation that third-party assistance was required

Documentation Required

Clinical visit documentation

Prescriber must indicate an in-person or telehealth visit within 6 months prior to ordering (or for previously approved members indicate visit confirming continued adherence/use) documenting that criteria are met.

In-person or telehealth visit within 6 months
For continuations: visit documenting continued adherence/use

Billing Rule

Length of approval

Approvals are granted for 12 months.

Approvals granted for 12 months

Clinical Background and Evidence

CGM provides more comprehensive glycemic data than standalone HbA1c or intermittent SMBG by recording continuous interstitial glucose values and enabling metrics such as time-in-range, time in hypoglycemia, and glucose variability that SMBG and HbA1c cannot capture.

Real-time CGM (rtCGM) can alert users to trends and impending hypo- or hyperglycemia, whereas intermittently viewed CGM (iCGM) provides retrospective continuous measurements and requires scanning to view trends.

The American Diabetes Association (ADA) recommends offering rtCGM for adults on basal insulin who can use the devices safely and considers CGM early in insulin-requiring diabetes; these statements and international consensus guidance are cited as supporting evidence (e.g., ADA Standards of Care 2024, International Consensus on Use of CGM).

References include the International Consensus on CGM and ADA Standards of Care 2024 supporting the clinical rationale for CGM use.

Name	Number	Type	Effective Date
Glucose Monitors	L33822	LCD
Glucose Monitor Policy Article	A52464	LCA

Revision History

clarified

Multiple administrative additions over time (addition of devices such as Dexcom G7, Guardian 4, FreeStyle Libre 3 Sensor/Reader, Simplera Sync Sensor, FreeStyle Libre 2 Plus Sensor).

03/2022administrative action

Administrative Action (Addition of Dexcom G7)

05/2023administrative action

Administrative Action (addition of Guardian 4)

05/2023administrative action

Administrative Action (addition of FreeStyle Libre 3 Sensor)

08/2023administrative action

Administrative Action (addition of FreeStyle Libre 3 Reader)

02/2024administrative action

Administrative Action (addition of FreeStyle Libre 3 Sensor)

07/2024administrative action

Administrative Action (addition of FreeStyle Libre 2 Plus Sensor)

02/2025administrative action

Annual Review Part B criteria, with changes to criteria, approved by P&T UM Committee

02/2025administrative action

Administrative Action (addition of Simplera Sync Sensor)

06/2020administrative action

Original Part B criteria, approved by P&T UM Committee

03/2021administrative action

Annual Review Part B criteria, with changes to criteria, approved by P&T UM Committee

06/2021administrative action

Mid-Year Review Part B criteria, with changes to criteria, approved by P&T UM Committee

02/2022administrative action

Annual Review Part B criteria, with changes to criteria, approved by P&T UM Committee

01/2023administrative action

Annual Review Part B criteria, criteria maintained, approved by P&T UM Committee

11/2023administrative action

Annual Review Part B criteria, criteria maintained, approved by P&T UM Committee

10/2024administrative action

Annual Review Part B criteria, with changes to criteria, approved by P&T UM Committee

OpenPayer

continuous_glucose_monitor_policy

Coverage Summary

Evaluation and Approval Criteria

Codes and Product Listings

Actions Required from Ordering Providers

Clinical Background and Evidence

Medicare LCD/LCA References

Revision History