Continuous Glucose Monitors (CGMs) — Prior Authorization and Benefit Limits
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Governs prior authorization criteria and member benefit limits for Continuous Glucose Monitors (receivers, transmitters, sensors, readers/monitors) and associated NDC/GPI lists for Capital Bluecross members in NC.
No material clinical or coverage changes in this revision.
Coverage and Prior Authorization Criteria
Prior Authorization Quantity Criteria
Covered when ONE of the following is met:
Approval length determined by prescriber's anticipated course of therapy unless superseded by source limits
This policy governs prior authorization and member benefit limits for continuous glucose monitoring systems (CGMs) and their components. It does not list explicit clinical exclusions; instead, the document focuses on benefit limits for device components (receivers/monitors, transmitters, sensors) and enumerates the applicable product identifiers (NDCs and GPIs) used to determine coverage and quantity limits.
Prior authorization determinations hinge on quantity limits. If a requested quantity exceeds the program benefit limit, the provider must supply clinical information supporting the need for a higher quantity. Requests that exceed the program quantity limits without such supporting information are at risk for denial.
Product Codes, NDCs, GPIs and Benefit Limits
| 08627-0091-** | NDC listed for Dexcom components (as provided) |
| 08627-0016-** | NDC listed for Dexcom components (as provided) |
| 08627-0053-** | NDC listed for Dexcom components (as provided) |
| 08627-0078-01 | NDC listed for Dexcom G7 receiver |
| 08627-0077-01 | NDC listed for Dexcom G7 sensor |
| 76300-0008-05 | NDC listed |
| 57599-0000-21 | NDC listed |
| 57599-0002-** | NDC listed |
| 57599-0000-19 | NDC listed |
| 57599-0001-** | NDC listed |
| 97202012026200 | GPI listed for CGM components |
| 97202012066300 | GPI listed for CGM components |
| 97202012046300 | GPI listed for CGM components |
| 76300-0239-82 | NDC listed (Guardian/Minimed family) |
| 76300-0100-01 | NDC listed |
| 43169-0704-05 | NDC listed |
| 63000-0179-62 | NDC listed |
| 76300-0100-02 | NDC listed |
| 76300-0179-62 | NDC listed |
| 76300-0725-01 | NDC listed |
| 43169-0800-40 | NDC listed |
| 76300-7701-01 | NDC listed |
| 63000-0413-38 | NDC listed |
| 63000-0956-40 | NDC listed under Benefit Limit Criteria |
Provider Requirements and Authorization Process
Quantity-based prior authorization requirement
Prior authorization will be approved only if the requested quantity does not exceed the program quantity limit or the request includes clinical information supporting therapy with a higher quantity; approval length is based on the prescriber's anticipated course of therapy unless superseded by source limits.
- Program quantity limits (example): 1 receiver / 365 days; 1 transmitter / 90 days; 3–5 sensors per 28–30 days (product-specific).
Step therapy not specified
The policy does not specify a required step-therapy sequence or prior trial of another product before authorization; no explicit step therapy language is stated.
Required documentation for quantity
Providers must document that the requested quantity is within the program quantity limit or must provide clinical justification/supporting information when requesting quantities above the program limit; reference product-specific NDC/GPI and benefit limits when documenting.
- Reference NDCs/GPIs and the program limits listed in the policy (e.g., receivers, transmitters, sensors) when submitting justification.
- Include clinical rationale explaining why standard quantity limits are insufficient for the member.
Quantity over program limit without justification
Requests that exceed the program quantity limit without submitted clinical justification may be denied as not meeting the authorization criteria.
- Example program limits from the policy: 1 receiver per 365 days; 1 transmitter per 90 days; 4 sensors per 28 days (product-dependent).
Background on Continuous Glucose Monitoring Systems
Continuous glucose monitoring systems consist of three primary components: a receiver/monitor (device for displaying CGM data), a transmitter (sends sensor data to the receiver), and disposable sensors (adhesive glucose sensing elements). The policy specifies device-specific supply limits: 1 receiver/monitor per 365 days, transmitters vary by product with common intervals of 1 per 90–365 days, and sensors are limited by product to typically 3–5 sensors per 28–30 days (many systems use 4 sensors/28 days). These component limits are applied against the NDC/GPI lists in the policy when evaluating prior authorization requests.
Device Component Definitions
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