Continuous Glucose Monitor
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This policy governs prior authorization requirements and coverage criteria for prescription continuous glucose monitors (Dexcom and FreeStyle Libre) for Medicare and Commercial members of Care Continuum.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial and ongoing coverage criteria
Covered when ALL of the following are met
Based on policy statement requiring prior authorization
Required medical information per policy
Applies only to Medicare line of business
This policy does not list any exclusion criteria. None listed.
Covered Devices and Codes
| Dexcom | Named continuous glucose monitor manufacturer/device |
| FreeStyle Libre | Named continuous glucose monitor manufacturer/device |
| Dexcom | Named continuous glucose monitor manufacturer/device |
| FreeStyle Libre | Named continuous glucose monitor manufacturer/device |
Provider Actions and Authorization
Prior authorization required for Dexcom and FreeStyle Libre CGMs
Prior authorization must be obtained for prescription drug coverage of Dexcom and FreeStyle Libre continuous glucose monitors; authorization is granted only when the policy criteria are met and required medical information is provided.
No step therapy or prescriber restrictions specified
No step therapy or prescriber restrictions are specified in this policy; coverage is limited by the listed clinical criteria and, for Medicare members, an FDA‑approved indication not otherwise excluded from Part D.
Required medical information: diagnosis
Clinical documentation submitted with the authorization request must include the member's diagnosis.
- Acceptable diagnoses: gestational diabetes, type 1 diabetes mellitus, or type 2 diabetes mellitus.
Prior authorization missing — risk of denial
If there is no prior authorization on file for prescription coverage of Dexcom or FreeStyle Libre CGM, coverage may be denied until authorization is obtained.
Covered Uses / Definitions
Background
Continuous glucose monitors (CGMs) provide ongoing interstitial glucose measurements useful for management of diabetes. This policy addresses coverage and prior authorization for prescription CGM devices (Dexcom and FreeStyle Libre) for Medicare and Commercial members. Covered uses include: for Medicare, an FDA‑approved indication not otherwise excluded from Part D; for Commercial, management of diabetes including members with a diagnosis of gestational, type 1, or type 2 diabetes mellitus. The policy requires prior authorization and documentation of the member’s diagnosis; there are no age or prescriber restrictions listed.
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