CurrentCignaPolicy v031526

Patient information and prior authorization form for continuous glucose monitoring (CGM) and related diabetes supplies

This document is a Cigna patient information/prior authorization form used by providers to request coverage for CGM devices, transmitters, sensors, receivers, and related supplies for patients with diabetes. It affects prescribing clinicians, servicing providers/dispensing vendors, and Cigna pharmacy review staff.

Policy Summary

PayerCigna

PolicyPatient information and prior authorization form for continuous glucose monitoring (CGM) and related diabetes supplies

Policy CodePolicy v031526

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete all required asterisked fields, include HCPC/CPT code selection and ICD-10 diagnosis, indicate quantity/duration, and provide prescriber signature to initiate prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40distinct device/supply checkboxes listed

4required patient/provider data items marked with *

3supply source options

5standard response time (business days)

Coverage Criteria and Form-Based Medical Necessity

Form-based medical necessity supporting criteria

Coverage considerations are supported by clinical attestation fields on the form; no explicit numerical clinical criteria are provided in this document.

Form completeness: All required asterisked patient and provider fields, HCPC/CPT code selection, ICD-10 diagnosis, quantity/duration, and prescriber signature must be provided on the form.

Supports prior authorization review initiation.

Diagnosis and insulin regimen: Provider must indicate diabetes type (Type 1, Type 2, or Other) and attest whether patient uses multiple daily injections, long‑acting basal insulin, or an insulin pump.

Used to justify need for CGM/supplies.

The form presents a selectable list of specific continuous glucose monitoring (CGM) devices, transmitters, receivers, sensors and related supply kits for the provider to indicate the exact item requested. Examples listed on the form include multiple Dexcom models (G4, G5, G6, G7), Freestyle Libre sensors/readers (10‑day, 14‑day, 2, 3 and Plus variants), Eversense sensors and transmitters, Guardian/Minimed sensor and transmitter kits, and other named sensor systems and kits. The document uses checkboxes for roughly ~40 distinct device/supply entries so providers can specify the precise product to be authorized.

Policy Summary

PayerCigna

PolicyPatient information and prior authorization form for continuous glucose monitoring (CGM) and related diabetes supplies

Policy CodePolicy v031526

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete all required asterisked fields, include HCPC/CPT code selection and ICD-10 diagnosis, indicate quantity/duration, and provide prescriber signature to initiate prior authorization.

SourceLink

On This Page

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Provider Actions, Prior Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required. Submit the completed Prior Authorization form (all asterisked fields) via CoverMyMeds (www.covermymeds.com/main/prior-authorization-forms/cigna/) or SureScripts in your EHR. Our standard response time for prescription drug coverage requests is 5 business days; call if urgent to request expedited review.

Prior Authorization required via form
Submit electronically at CoverMyMeds or via SureScripts in EHR

Denial Risk

Complete All Mandatory Fields

Incomplete or missing mandatory fields (asterisked items) on the prior authorization form may delay or prevent us from responding. We will not be able to respond via fax unless all required (*) items are completed.

Ensure all asterisked (*) fields are completed (patient identifiers, provider identifiers, Cigna ID, DOB, etc.)
Missing billing codes or diagnosis may prevent processing of the request

Documentation Required

Required Documentation and Identifiers

Provide required documentation and identifiers with the request: patient name, Cigna ID, date of birth, patient address and phone; physician name, specialty, DEA/NPI or TIN, office contact, phone and fax; servicing provider/dispensing vendor name, tax ID, address, phone, fax. Include clinical information, ICD-10 diagnosis, HCPCS/CPT and/or NDC codes, directions for use, quantity, and duration of therapy.

Patient: full name, Cigna ID, Date of Birth, street address, phone
Provider: Physician name, specialty, DEA/NPI or TIN, office contact, phone, fax
Servicing provider/vendor: name, state, tax ID, address, phone, fax
Clinical: ICD-10 diagnosis, pertinent clinical information, attestation and prescriber signature
Coding: HCPCS/CPT (e.g., A4238, A9276, A9277, A9278, E2102, A4239, E2103) and quantity/duration

Note

Vendor Selection for Dispensing Supplies

Indicate where supplies will be obtained and select the dispensing vendor: Express Scripts Pharmacy (Cigna's nationally preferred specialty pharmacy), retail pharmacy, DME vendor, or other. Provide the servicing/dispensing vendor details on the form.

Select vendor: Express Scripts Pharmacy (preferred), retail pharmacy, DME vendor, or other (specify)
If DME or other vendor selected, include vendor name, address, state, tax ID, phone, fax

Definitions and Selectable Diagnosis / Regimen Options

Diagnosis options — selectable entries

Diagnosis optionsType 1 diabetes mellitus (DM); Type 2 diabetes mellitus (DM); Other (Please specify)

UsageSelectable diagnosis entries on the prior-authorization form to indicate patient’s diabetes type

PurposeUsed to justify medical necessity for continuous glucose monitoring systems and related supplies

Insulin regimen attestation (MDI, basal, CSII)

Insulin regimen attestationMultiple daily injections; long‑acting basal insulin (e.g., glargine, detemir, degludec, NPH); continuous subcutaneous external insulin pump

Question formatForm asks: ‘Is the patient on ANY of the following insulin regimens: 1. multiple daily injections; 2. long‑acting basal insulin; or 3. continuous subcutaneous external insulin pump? Yes No’

Attestation requirementPrescriber must attest that the information is true and provide signature and date on the form

OpenPayer

Patient information and prior authorization form for continuous glucose monitoring (CGM) and related diabetes supplies

Coverage Criteria and Form-Based Medical Necessity

HCPCS / CPT / Code Listings from the Form

Provider Actions, Prior Authorization, and Documentation Requirements

Background and Intended Use

Definitions and Selectable Diagnosis / Regimen Options

A4238
A9276
A9277
A9278
E2102
A4239
E2103
Other	please specify