CurrentCapital BluecrossPolicy N/A

Continuous Glucose Monitors (CGMs) benefit limits and prior authorization criteria

This document defines prior authorization criteria and member benefit limits for continuous glucose monitoring (CGM) devices, transmitters, receivers, sensors and related kit components for Capital Bluecross members.

Policy Summary

PayerCapital Bluecross

PolicyContinuous Glucose Monitors (CGMs) benefit limits and prior authorization criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when the requested quantity exceeds the program quantity limit; approval length is based on the prescriber's anticipated course of therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/365 dayscommon receiver benefit limit

1/365 daystransmitter benefit limits

4/28 dayssensor supply limit

NDC list >20listed product NDC codes

Multiplemanufacturers referenced

Policy Summary

PayerCapital Bluecross

PolicyContinuous Glucose Monitors (CGMs) benefit limits and prior authorization criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when the requested quantity exceeds the program quantity limit; approval length is based on the prescriber's anticipated course of therapy.

SourceLink

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CGM Benefit and Authorization Criteria

Benefit limits and prior authorization criteria for continuous glucose monitor (CGM) components are specified by product/part numbers and grouped by receivers, transmitters, sensors, and kits. Coverage requires meeting the program quantity limits or submission of supporting information for quantities above those limits.

ALL of the following

Requested quantity does NOT exceed the program quantity limit (no additional information required).
If requested quantity exceeds program limit
- Information provided in support of therapy with a higher quantity (documentation of medical necessity).
Length of approval shall be determined based upon the prescriber's anticipated course of therapy, unless there is a superseding limitation in the source used to determine reasonable and necessary.

ALL of the following

1 receiver per 365 days.
1 transmitter per 90 days (note: some entries list 1 transmitter per 365 days for certain products).
4 sensors per 28 days (common), with some product entries listing 3 sensors per 30 days or 5 sensors per 30 days as applicable.
1 reader per 365 days (where applicable).

ALL of the following

Policy references multiple product NDCs and GPIs, including Dexcom G6 receiver, Dexcom G6 transmitter, Dexcom G6 sensor, Enlite glucose sensor, and listed NDCs (examples: 08627-0091-**, 08627-0016-**, 76300-0008-05, 57599-0000-21).

Product Codes, NDCs and Supply Thresholds

Example NDCs referencedNDC

08627-0091-**	Dexcom G6 sensor (example)
08627-0016-**	Dexcom G6 transmitter (example)
08627-0053-**	Dexcom G6 receiver (example)
08627-0078-01	Dexcom receiver sensor (example)
08627-0077-01	Dexcom receiver sensor variant
76300-0008-05	Enlite glucose sensor (example)
57599-0000-21	CGM component NDC
57599-0002	CGM component NDC
57599-0000-19	CGM component NDC
57599-0001	CGM component NDC

1–10 of 36

1/4

Common supply thresholds

Receiver1 unit per 365 days

Transmitter1 unit per 90-365 days depending on system

Sensor3-5 sensors per 28-30 days depending on system

Reader/Monitor1 unit per 365 days

Prior Authorization and Provider Requirements

Prior Authorization

Prior authorization required when request exceeds program quantity limit

Prior authorization is required when the requested quantity exceeds the program quantity limit. Length of approval will be determined based on the prescriber's anticipated course of therapy unless a superseding limitation applies in the source used to determine reasonable and necessary care.

If the requested quantity does not exceed the program quantity limit, standard prior authorization is not required per criteria A.
If a higher quantity is requested, documentation supporting the need for the higher quantity must be provided per criteria B.

Benefit Limit Definitions

Member Friendly Benefit Limit

DefinitionA simplified, member-facing statement of the allowed supplies and frequency for CGM components (e.g., '1 receiver per 365 days; 1 transmitter 90–365 days; 4 sensors per 28 days').

PurposeProvides members an easy-to-understand summary of their benefit limits for receivers, transmitters, sensors, and readers.

ApplicabilityApplies to CGM products and multi-source NDCs listed in the policy; exact limits vary by product family.

System Setup Benefit Limit

DefinitionThe initial setup or kit allowance that covers baseline CGM components when starting therapy (examples include 1 receiver or 1 monitor or 1 transmitter per 365 days, and associated starter kits).

Common limitsSystem setup entries in the policy include: 1 receiver/365 days; 1 transmitter/365 days; kit 365 days; 4 sensors/28 days (as noted per product).

UseUsed to determine coverage for initial device provision or replacement as part of system setup; varies by specific product NDC/kit.