CurrentFlorida BluePolicy N/A

Continuous Glucose Monitor (CGM) prior authorization request

Form and requirements for providers to request prior authorization for CGM devices or supplies for Florida Blue members; applies to prescribers submitting requests under the member's Part B (medical/DME) benefit.

Policy Summary

PayerFlorida Blue

PolicyContinuous Glucose Monitor (CGM) prior authorization request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required clinical documentation and a new prescription to an in‑network or participating home delivery pharmacy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72 hrsstandard review timeframe

24 hrsexpedited review timeframe

6 monthsvisit recency requirement

Part Bbenefit processed under

Coverage and Medical Necessity

Authorization criteria

Covered when ALL required administrative and clinical documentation are submitted and internal medical necessity criteria are met.

Form completion: Completed prior authorization form submitted (one per request), legible, with prescriber signature and date/time

Chunks 0,3

Clinical encounter: Treating practitioner had an in-person or Medicare-approved telehealth visit within the prior six months to evaluate diabetes control and determine CGM criteria are metwithin 6 months

Chunk 3

Documentation attached: Pertinent medical history, progress notes, laboratory and diagnostic test results and clinical rationale for CGM including diagnosis codes, insulin use status, and requested product details are attached

Policy Summary

PayerFlorida Blue

PolicyContinuous Glucose Monitor (CGM) prior authorization request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required clinical documentation and a new prescription to an in‑network or participating home delivery pharmacy.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Diagnosis, Product Identifiers, and Clinical Visit Timing

Requested diagnosis and product identifiersmixed

ICD-10 and Z codes	Diagnosis must be provided with ICD-10 and applicable Z codes as requested on the form
NDC	NDC for CGM brand/model/supplies requested

Clinical visit recency — within six (6) months prior to ordering

RequirementTreating practitioner must have had an in-person or Medicare‑approved telehealth visit within six (6) months prior to ordering the CGM to evaluate diabetes control and determine CGM criteria are met

Documentation fieldDate of last visit with treating practitioner must be provided on the form

Continuing therapy noteIf continuing therapy, include prior Florida Blue approval certificate number on the form

What Providers Must Do

Prior Authorization

Submit prior authorization form and prescription

Complete the Florida Blue prior authorization form in full and submit one form per request. Fax the completed form or call the number listed on the form. Incomplete, illegible, or blank fields may delay the review process.

Fax: 1-904-357-6699
Phone: 1-904-357-3900 Ext. 89277

Prior Authorization

Continuation of therapy requirement

If the request is for continuation of therapy, include the prior Florida Blue approval certificate number on the form to allow evaluation as a continuation request.

Documentation Required

Required clinical documentation

Attach complete clinical documentation to support medical necessity. Include pertinent medical history, recent progress notes, laboratory and diagnostic test results, the clinical rationale for CGM use, diagnosis with ICD-10 (and Z codes if applicable), CGM brand/model and NDC, whether the member is currently on insulin, dates of relevant visits (including an in-person or Medicare‑approved telehealth visit within six months prior to ordering), quantity required per month, start date of therapy, and a new prescription for the requested CGM to an in‑network or participating home delivery pharmacy when applicable.

Denial Risk

Incomplete or missing documentation may delay/deny

Missing, incomplete, or slow-to-arrive documentation may delay or result in denial of the request. Ensure all requested fields are legible and attachments are included with the submission.

Clinical Background

Continuous glucose monitoring (CGM) systems provide ongoing glucose measurements and associated supplies for patients with diabetes. The form requests the CGM brand/model and NDC, the diabetes diagnosis with ICD-10/Z codes, insulin use status, clinical rationale for CGM, and whether the member is currently using CGM. It also requires that the treating practitioner have had an in-person or Medicare‑approved telehealth visit within six (6) months prior to ordering to evaluate diabetes control. Providers must submit a completed, signed form with supporting medical history, progress notes, laboratory and diagnostic results, and a new prescription to an in‑network or participating home delivery pharmacy if approved; if continuing therapy, include the prior Florida Blue approval certificate number. Missing information or slow responses can delay or result in denial of the request.

OpenPayer

Continuous Glucose Monitor (CGM) prior authorization request

Coverage and Medical Necessity

Diagnosis, Product Identifiers, and Clinical Visit Timing

What Providers Must Do

Benefit Definitions

Clinical Background