CurrentCignaPolicy N/A

Diabetes - FreeStyle Libre Sensors Drug Quantity Management Policy - Per Days

Defines quantity limits and medically necessary exceptions for FreeStyle Libre glucose monitoring sensors supplied to Cigna members, including FreeStyle Libre 14 Day, Libre 2, Libre 2 Plus, Libre 3, and Libre 3 Plus sensors.

Policy Summary

PayerCigna

PolicyDiabetes - FreeStyle Libre Sensors Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNew policy with one-time override provision

Effective DateN/A

Next Review DateMay 6, 2026

Key ActionIf a sensor fails before expected wear time, submit for a one-time override to approve 2 additional sensors.

SourceLink

POLICY UPDATE CHANGES

New policy created to provide overrides for existing quantity limits to approve 2 additional sensors when a sensor requires replacement prior to expected wear time.

14 daysmost sensors wear duration

15 daysPlus sensors wear duration

2one-time override quantity

6home delivery max

Coverage Criteria for FreeStyle Libre Sensors

Policy Summary

PayerCigna

PolicyDiabetes - FreeStyle Libre Sensors Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNew policy with one-time override provision

Effective DateN/A

Next Review DateMay 6, 2026

Key ActionIf a sensor fails before expected wear time, submit for a one-time override to approve 2 additional sensors.

SourceLink

On This Page

Initial override criteria — FreeStyle Libre 2, Libre 3, Libre 14 Day

Exceptions to the quantity limits are covered as medically necessary when the following are met for 14-day sensors:

One-time override for 14-day sensors: If the patient's sensor required replacement sooner than the expected 14 days, approve a one-time override for 2 additional sensors at retail or home delivery.one-time override = 2 sensors

A sensor may require replacement prior to the expected 14 days for a variety of reasons, including but not limited to premature adhesive failure (i.e., peeling off), insertion issues, sensor signal loss, and connectivity issues.

Initial override criteria — FreeStyle Libre 2 Plus, Libre 3 Plus

Exceptions to the quantity limits are covered as medically necessary when the following are met for Plus (15-day) sensors:

One-time override for Plus sensors: If the patient's sensor required replacement sooner than the expected 15 days, approve a one-time override for 2 additional sensors at retail or home delivery.one-time override = 2 sensors

A sensor may require replacement prior to the expected 15 days for a variety of reasons, including but not limited to premature adhesive failure (i.e., peeling off), insertion issues, sensor signal loss, and connectivity issues.

Exceptions to the quantity limits listed in this policy are covered as medically necessary only when they meet the specific criteria set forth for FreeStyle Libre sensors. Any exception other than the listed criteria is considered not medically necessary. Coverage decisions will follow the criteria described elsewhere in this policy for sensor replacement prior to expected wear time.

The Drug Quantity Limits shown in this policy (retail and home delivery maximums by product) are enforced; exceptions to these quantity limits that do not meet the specified criteria are considered not medically necessary. Providers seeking additional sensors beyond the listed limits must document that the request satisfies the one-time override criteria detailed in this policy.

Provider Responsibilities, Billing and Quantity Management

Prior Authorization

Quantity limits enforced; overrides available

Quantity limits are enforced at point of service. If the submitted quantity exceeds the Drug Quantity Management limits, a one-time override (approval) may be granted when the exception criteria are met. One-time approvals are provided for a 30-day duration; other approvals are provided for the duration specified in the approval.

One-time overrides available for 30 days when exception criteria are satisfied
Quantity limits apply per product and supply channel (retail vs home delivery) as listed in policy

Billing Rule

Provider billing and submission requirements

Providers must submit claims using the most appropriate and current diagnosis and procedure codes as of the date of submission. Claims for services not accompanied by covered code(s) under the applicable coverage policy will be denied as not covered. When the Drug Quantity Management rule is not met at point of service, follow the coverage determination and override request procedures in this policy.

Ensure billing uses codes effective on the date of service
Claims lacking covered diagnosis/procedure codes will be denied

Prior Authorization

Coverage determination and override process when quantity rule not met

When the Drug Quantity Management rule is not met at point of service, coverage will be determined by the policy criteria. If an exception is requested, submit supporting clinical documentation demonstrating that the exception criteria are met. Approvals granted through the exception process will indicate the duration of coverage; one-time approvals are 30 days. If the request does not meet the exception criteria, the claim/authorization will be denied and standard appeal processes apply.

Submit clinical rationale and documentation to support the exception criteria
Approved exceptions will state the duration (one-time = 30 days unless otherwise noted)
Denials will follow normal claims and appeal procedures

Denial Risk

Claims without covered diagnosis/procedure codes will be denied

Claims submitted for services that are not accompanied by covered diagnosis and/or procedure codes under this coverage policy will be denied as not covered. To avoid denials, verify that the diagnosis and procedure codes used are included in the applicable coverage policy and are current as of the date of submission.

Verify covered diagnosis/procedure codes before submission
Claims with non-covered or incorrect codes will be denied

Background

The FreeStyle Libre systems are continuous glucose monitoring devices comprised of a disposable sensor worn on the body and a reader or compatible mobile device used to view glucose data. The systems (FreeStyle Libre 2, FreeStyle Libre 3, and FreeStyle Libre 14 Day) are intended to replace fingerstick blood glucose testing for diabetes treatment decisions in appropriate patients; age indications vary by product. Additionally, the Plus versions of the sensors are authorized for use with automated insulin delivery systems. Typical sensor wear duration is 14 days for most FreeStyle Libre sensors and 15 days for the Plus sensor variants.

OpenPayer

Diabetes - FreeStyle Libre Sensors Drug Quantity Management Policy - Per Days

Coverage Criteria for FreeStyle Libre Sensors

Sensor Wear Duration and Coding Notes

Provider Responsibilities, Billing and Quantity Management

Definitions

Background