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    v1.0.31
    OpenPayerPolicy UpdatesEndocrinologyHealthy Blue Louisiana CGM Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentHealthy Blue LouisianaPolicy LAHB-CD-019081-23

    Louisiana Medicaid Continuous Glucose Monitoring Devices (CGMs)

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    This policy governs prior authorization, preferred product selection, quantity limits, step therapy, approval duration, and medical-necessity criteria for continuous glucose monitoring devices and supplies under Healthy Blue Louisiana Medicaid Managed Care.

    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyLouisiana Medicaid Continuous Glucose Monitoring Devices (CGMs)
    Policy CodePolicy LAHB-CD-019081-23
    Change TypeNo material change
    Effective DateApril 2023
    Next Review DateN/A
    Key ActionObtain prior authorization for all CGM agents, including sensors, transmitters, and receivers.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1 yearApproval duration for sensors and transmitters
    2 linesPreferred CGM product lines
    <50 mg/dLSevere hypoglycemia threshold
    3 conditionsReplacement conditions required
    1/yearTypical receiver quantity limit

    Medical Necessity and Coverage Criteria

    Initial personal long-term CGM therapy

    Personal long-term use may be approved when ANY of the following clinical pathways is met.

    Qualifying long-term CGM use

    • Type 1 diabetes with severe hypoglycemia risk: The individual has type 1 diabetes with recurrent, unexplained, severe hypoglycemia or impaired hypoglycemia awareness that places the beneficiary at risk.Severe hypoglycemia: glucose levels <50 mg/dL
    • Pregnancy with poorly controlled type 1 diabetes: The beneficiary is pregnant and has poorly controlled type 1 diabetes evidenced by recurrent unexplained hypoglycemic episodes, hypoglycemia unawareness, postprandial hyperglycemia, or recurrent diabetic ketoacidosis.
    • Diabetes with recurrent hypoglycemia and insulin dependence:
    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyLouisiana Medicaid Continuous Glucose Monitoring Devices (CGMs)
    Policy CodePolicy LAHB-CD-019081-23
    Change TypeNo material change
    Effective DateApril 2023
    Next Review DateN/A
    Key ActionObtain prior authorization for all CGM agents, including sensors, transmitters, and receivers.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaClinical Thresholds and Coding DetailsAuthorization, Documentation, and Decision RulesPolicy Background

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    The individual has diabetes mellitus of any type, recurring episodes of hypoglycemia, inadequate glycemic control despite multiple alterations in self-monitoring and insulin administration regimens to optimize care, and requires multiple daily insulin injections or uses a medically necessary insulin pump for maintenance of blood sugar control.

    All listed conditions in this pathway are required.

    Replacement therapy

    Replacement may be approved when ALL of the following are met.

    Replacement of CGM device

    • Out of warranty: The device is out of warranty.
    • Malfunctioning: The device is malfunctioning.
    • Not refurbishable: The device cannot be refurbished.

    Non-preferred CGM step therapy exception

    Non-preferred product requests may be approved when ANY of the following is met.

    Non-preferred CGM exception

    • Failed or intolerant preferred CGM trial: The individual has had a trial of one preferred CGM from the Dexcom or FreeStyle Libre product line and experienced an inadequate response or intolerance.

      Medication samples, coupons, and discount cards do not count as a trial.

    • Pump compatibility exception: The individual uses an insulin pump that is compatible only with a non-preferred CGM.

    CGM use may not be approved for indications that do not meet the policy’s stated criteria for personal long-term use, including cases where the qualifying clinical pathways have not been satisfied.

    Replacement of a currently functional and warranted device may not be approved. Replacement requires that the device be out of warranty, malfunctioning, and unable to be refurbished.

    Use for an indication that does not satisfy the policy’s qualifying clinical criteria is not approved, including indications outside the defined long-term-use pathways.

    Clinical Thresholds and Coding Details

    Severe hypoglycemia
    Severe hypoglycemia threshold<50 mg/dL

    Authorization, Documentation, and Decision Rules

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for all continuous glucose monitoring (CGM) agents and supplies, including sensors, transmitters, and receivers.

    • Applies to continuous interstitial glucose monitoring devices used for personal long-term use as an adjunct to standard care.
    Note

    Approval Duration

    Approval duration is based on the component requested: receiver approval is issued one time, while sensor and transmitter approval is issued for one year.

    • Receiver: one-time approval
    • Sensors and transmitters: one-year approval
    Step Therapy

    Step Therapy for Non-Preferred CGMs

    Requests for non-preferred CGM devices or supplies must satisfy step-therapy requirements before approval.

    • The individual has tried one preferred CGM (Dexcom Product Line or Freestyle Libre Product Line) and had an inadequate response or intolerance. Medication samples, coupons, and discount cards do not count as a trial.
    • The individual uses an insulin pump that is compatible only with a non-preferred CGM.
    Documentation Required

    Documentation Requirements

    Document the clinical basis for long-term CGM use and the requested product or replacement.

    • Diabetes type and relevant clinical circumstances, including recurrent unexplained severe hypoglycemia (glucose levels < 50 mg/dL), impaired hypoglycemia awareness, pregnancy with poorly controlled type I diabetes, recurrent diabetic ketoacidosis, or recurring hypoglycemia with inadequate glycemic control.
    • For the general diabetes pathway: multiple alterations in self-monitoring and insulin administration regimens must have been attempted, and multiple daily insulin injections or a medically necessary insulin pump must be used.
    • For replacement requests: document that the device is out of warranty, malfunctioning, and cannot be refurbished.
    • For non-preferred products: document the qualifying preferred-product trial and inadequate response or intolerance, or the use of an insulin pump compatible only with the requested non-preferred CGM.
    Denial Risk

    Denial Risk: Indication Criteria Not Met

    Long-term personal use may be denied when the request does not meet a qualifying indication or the required clinical criteria.

    • Qualifying indications include type I diabetes with recurrent unexplained severe hypoglycemia or impaired hypoglycemia awareness; pregnancy with poorly controlled type I diabetes meeting the specified circumstances; or diabetes of any type with recurring hypoglycemia, inadequate glycemic control despite regimen optimization, and multiple daily insulin injections or a medically necessary insulin pump.
    • CGM use may not be approved for other indications when the applicable criteria are not met.
    Denial Risk

    Denial Risk: Replacement Criteria Not Met

    Replacement of a continuous interstitial glucose monitoring device may be denied unless all replacement criteria are met.

    • The device must be out of warranty.
    • The device must be malfunctioning.
    • The device must not be capable of refurbishment.
    • Replacement of a currently functional and warranted device may not be approved when these criteria are not met.
    Denial Risk

    Denial Risk: Non-Preferred Product

    A non-preferred CGM product or supply may be denied when the request lacks a qualifying step-therapy exception.

    • A trial of one preferred CGM with inadequate response or intolerance is required; samples, coupons, and discount cards do not qualify as a trial.
    • An exception applies when the individual uses an insulin pump that is compatible only with a non-preferred CGM.

    Policy Background

    Continuous interstitial glucose monitoring devices provide ongoing glucose data as an adjunct to standard diabetes care. Coverage focuses on beneficiaries with clinically significant hypoglycemia risk, inadequate glycemic control despite treatment adjustments, insulin-dependent diabetes management, selected high-risk pregnancy circumstances, or qualifying device replacement needs.