CurrentCareSourcePolicy Arkansas PASSE

Continuous Glucose Monitors (CGMs) — Arkansas PASSE

This policy governs prior authorization and coverage criteria for continuous glucose monitors (pharmacy or medical benefit) for Arkansas PASSE members, specifying clinical requirements for approval and duration of coverage.

Policy Summary

PayerCareSource

PolicyContinuous Glucose Monitors (CGMs) — Arkansas PASSE

Policy CodePolicy Arkansas PASSE

Change TypeNew policy / alignment with HB1008

Effective DateApr 1, 2024

Next Review DateJan 8, 2025

Key ActionObtain prior authorization for CGMs; approvals are granted for 12 months when listed criteria are met.

SourceLink

POLICY UPDATE CHANGES

New policy for CGMs created to align with House Bill 1008.

12 monthsauthorization duration when criteria met

every 6 monthsfollow-up frequency

>2x/dayinsulin use criterion

Level 2/3hypoglycemia requirement

Arkansasstate

Coverage Criteria for Continuous Glucose Monitors

Policy Summary

PayerCareSource

PolicyContinuous Glucose Monitors (CGMs) — Arkansas PASSE

Policy CodePolicy Arkansas PASSE

Change TypeNew policy / alignment with HB1008

Effective DateApr 1, 2024

Next Review DateJan 8, 2025

Key ActionObtain prior authorization for CGMs; approvals are granted for 12 months when listed criteria are met.

SourceLink

On This Page

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Initial Therapy - FreeStyle Libre 2 & 3, Dexcom

Covered when ALL of the following are met for FreeStyle Libre 2 & 3, Dexcom:

Initial Authorization - FreeStyle Libre 2 & 3, Dexcom

Diabetes diagnosis: Presence of type 1 diabetes or any other type of diabetes
Insulin use: Use of insulin more than two (2) times daily
Glycogen storage disease: Diagnosis of glycogen storage disease type 1a
Hypoglycemia evidence: Evidence of Level 2 or Level 3 hypoglycemia
Follow-up: Regular follow-up visits with a healthcare provider at a minimum of every six (6) months to assess ongoing benefit of the continuous glucose monitor

Initial Therapy - Guardian, Eversense

Covered when ALL of the following are met for Guardian and Eversense:

Initial Authorization - Guardian, Eversense

Diabetes diagnosis: Presence of type 1 diabetes or any other type of diabetes
Insulin use: Use of insulin more than two (2) times daily
Glycogen storage disease: Diagnosis of glycogen storage disease type 1a
Hypoglycemia evidence: Evidence of Level 2 or Level 3 hypoglycemia

CareSource considers Continuous Glucose Monitors (CGMs) not medically necessary for the treatment of conditions that are not listed in this document. Requests for coverage for indications outside those explicitly specified in this policy will be evaluated against the Off-Label policy and are expected to be denied when they do not meet a listed indication.

Requests for CGMs for indications that are not specified in this policy are considered not medically necessary and may be denied. Providers must request coverage only for indications described in this document (for example, diabetes or glycogen storage disease type 1a where applicable) and should refer to the Off-Label policy for other uses.

Initial Therapy Authorization Rules

Initial Therapy — Initial authorization rules and required criteria

Initial authorization rules and required criteria

Initial Authorization Criteria

Diabetes diagnosis: Presence of type 1 diabetes or any other type of diabetes
Insulin use: Use of insulin more than two (2) times daily
Hypoglycemia evidence: Evidence of Level 2 or Level 3 hypoglycemia
Follow-up: Regular follow-up visits with a healthcare provider at a minimum of every six (6) months to assess ongoing benefit

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Prior Authorization Required for CGMs

Prior authorization is required for Continuous Glucose Monitors (CGMs). When the listed clinical criteria are met, approvals are issued for 12 months.

Benefit type: Pharmacy or Medical
Approval duration: 12 months when criteria met

Step Therapy

Device-specific Step/Preference Note

For device-specific requests (for example, Guardian or Eversense), the request must include a clear clinical reason why FreeStyle Libre cannot be used for the member.

Applies to Guardian and Eversense device requests
Provider must document why FreeStyle Libre 2/3 (or Dexcom when applicable) is not suitable

Documentation Required

Required Clinical Documentation

Required clinical documentation must be submitted with the prior authorization request to demonstrate medical necessity.

Diagnosis of diabetes (type 1, type 2, or other specified diabetes) or glycogen storage disease type 1a as applicable
For initial authorization: documentation of insulin use more than two (2) times daily OR other qualifying indication
Evidence of Level 2 or Level 3 hypoglycemia when claimed
Documentation of regular follow-up plan with a healthcare provider at minimum every six (6) months to assess ongoing benefit
Clinical rationale and supporting documentation if requesting a non-preferred device (see device-specific step/preference note)

Denial Risk

Off-Label/Not Listed Indications

Requests for CGMs for indications not listed in this policy will be considered not medically necessary and may be denied.

CareSource considers CGMs not medically necessary for conditions not enumerated in this policy
Refer to the plan's Off-Label policy for requests outside listed indications

Step Therapy / Device Preference

Device	Requirement before approval (reason FreeStyle Libre cannot be used)
Guardian	Provider must document a clinical reason why FreeStyle Libre cannot be used for the member (device‑specific requirement); this clinical rationale must be submitted as part of the prior authorization request before Guardian will be approved.
Eversense	Provider must document a clinical reason why FreeStyle Libre cannot be used for the member (device‑specific requirement); this clinical rationale must be submitted as part of the prior authorization request before Eversense will be approved.

Background

Continuous Glucose Monitors (CGMs) are compact medical systems that use a subcutaneous sensor to measure interstitial glucose frequently and transmit data to a display device. They provide near‑real‑time glucose values and trend information and are particularly valuable for patients and caregivers who will use the device consistently, including those with hypoglycemia unawareness or a history of severe or recurrent hypoglycemia. Regular clinical follow-up is necessary to assess ongoing benefit.

Definitions

Continuous Glucose Monitor (CGM) — definition

DefinitionContinuous Glucose Monitors (CGMs) are compact medical systems that use a subcutaneous sensor to measure interstitial glucose levels in close to real-time (every 5 to 15 minutes) and send the data wirelessly to a monitor device.

Measurement mediumMeasure interstitial glucose (not capillary blood).

Sampling frequencyProvides glucose measurements approximately every 5 to 15 minutes, depending on the device.

Data transmissionSends data wirelessly to a display/monitor device to show trends and alerts.

Primary beneficiariesMost beneficial for patients and caregivers willing to use them consistently and for patients with hypoglycemic unawareness or history of severe recurrent hypoglycemia.

Self‑monitoring of Blood Glucose (SMBG) — definition

DefinitionSelf-monitoring of blood glucose (SMBG) is intermittent capillary blood sampling using a reagent strip, cartridge, or cuvette with a drop of capillary blood from a finger puncture to measure blood glucose concentration.

Sampling methodCapillary blood obtained via finger puncture.

FrequencyIntermittent (performed as needed rather than continuous).

Contrast with CGMSMBG provides point-in-time capillary blood glucose values versus CGM which provides near real-time interstitial glucose trends and alerts.

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