Continuous Glucose Monitors (FreeStyle Libre) — Prior Authorization Criteria
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Defines prior authorization coverage criteria and administrative details for select FreeStyle Libre continuous glucose monitor devices for Georgia Medicaid Fee‑For‑Service members.
No material clinical or coverage changes in this revision.
Coverage Criteria for FreeStyle Libre CGM
Initial Authorization Criteria
Covered when ANY of the following are met
Approvable for members with gestational diabetes.
Approvable when treated with >=1 daily insulin dose.
Approvable for persistent problematic hypoglycemia.
Includes events requiring assistance.
Approvable for nocturnal or unrecognized hypoglycemia.
This policy does not list any explicit clinical exclusions for continuous glucose monitor (CGM) coverage. Instead, exceptions to coverage are handled through the prior authorization process; providers should initiate a prior authorization request when an exception is being sought.
There are no conditions described in this document that are labeled as explicitly "not medically necessary." The policy lists covered FreeStyle Libre device variants and relies on prior authorization criteria to determine medical necessity for individual members.
Coding and Clinical Thresholds
| No codes listed |
Provider Actions and Prior Authorization
Prior authorization required (1‑year authorizations)
Prior authorization is required for FreeStyle Libre devices; authorizations are issued for up to 1 year. Initiate the PA through OptumRx (1-866-525-5827) or follow the DCH PA Request Process Guide online.
No step therapy required
This policy does not impose any step therapy or trial requirements for approval.
How to request prior authorization
Exceptions and PA requests may be initiated by calling OptumRx (1-866-525-5827); online PA submission guidance is available via the DCH Prior Authorization (PA) Request Process Guide.
- Phone: OptumRx 1-866-525-5827
- Online PA process and guide: www.dch.georgia.gov/priorauthorization-process-and-criteria
Eligibility documentation required — risk of denial if missing
Document a qualifying diagnosis and clinical details showing the member meets one of the approvable criteria; requests lacking documentation of gestational diabetes, diabetes treated with at least one daily dose of insulin, or specified hypoglycemia criteria may be denied.
- Diagnosis of gestational diabetes; or
- Diagnosis of diabetes with treatment of at least one daily dose of insulin; or
- Diabetes with problematic hypoglycemia (glucose < 54 mg/dL persisting despite medication adjustments); or
- Diabetes with hypoglycemia events requiring third‑party assistance or with nocturnal hypoglycemia/hypoglycemia unawareness
Background
Continuous glucose monitors (CGMs) provide ongoing interstitial glucose readings and are used to support glucose management in people with diabetes, including gestational diabetes. This policy specifically lists covered FreeStyle Libre sensors, readers, and kits and ties approval to documented clinical indications such as pregnancy-related diabetes, diabetes treated with insulin, or clinically significant hypoglycemia.
Definitions
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