CurrentIndependent HealthPolicy M20221212131

Continuous glucose monitors and supplies- Medicare

Governs coverage, prior authorization, and supply limits for therapeutic and non-therapeutic continuous glucose monitors (CGMs) and related supplies for Independent Health Medicare lines of business.

Policy Summary

PayerIndependent Health

PolicyContinuous glucose monitors and supplies- Medicare

Policy CodePolicy M20221212131

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review Date

Key ActionObtain prior authorization for new CGM starts unless the member is on insulin and eligible for retail pharmacy dispensing without PA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Preferred therapeutic CGMs listed

YesRetail pharmacy no PA when on insulin

IndefiniteDuration of approval if criteria met

9Max Dexcom sensors / 90 days

Coverage Criteria for Continuous Glucose Monitors

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.

Pharmacy authorization medical necessity criteria

Covered when ALL of the following are met:

Primary condition: Member has a diagnosis of diabetes

Clinical indication: Member is using insulin OR Member has a history of problematic hypoglycemia

Problematic hypoglycemia requires either recurrent (>1) level 2 events (glucose <54 mg/dL) that persist despite multiple (>1) attempts to adjust medications/plan OR a history of one level 3 event (altered mental/physical state requiring third‑party assistance).

Device use definitions: Therapeutic (non‑adjunctive) CGM may replace fingerstick testing for diabetes treatment decisions; non‑therapeutic (adjunctive) CGM must be used with fingerstick testing and cannot be used for insulin dosing decisions.

CGM devices that display glucose results only on a smartphone and do not include a separate, stand-alone receiver or the capability to integrate with an insulin infusion pump do not meet the policy’s definition of Durable Medical Equipment (DME). Such smartphone-only systems lack the required receiver/integration functionality and therefore are excluded from DME coverage under this policy.

Non-DME, smartphone-only continuous glucose monitors are considered not covered (no benefit) under this policy. Devices that solely display results on a smartphone without a stand-alone receiver or integration into an insulin infusion pump will be denied as non-covered.

Billing and Coding

Covered HCPCS CodesHCPCSCovered

E2102	ADJUNCTIVE CONTINUOUS GLUCOSE MONITOR OR RECEIVER
E2103	NON-ADJUNCTIVE, NON-IMPLANTED CONTINUOUS GLUCOSE MONITOR OR RECEIVER
A4238	SUPPLY ALLOWANCE FOR ADJUNCTIVE CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE
A4239	SUPPLY ALLOWANCE FOR NON-ADJUNCTIVE, NON-IMPLANTED CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE

Prescription history lookback for insulin — 108 days

Lookback period108 days (prescription history check for concurrent or prior insulin use)

PurposeDetermines retail pharmacy no-prior-authorization eligibility when insulin use documented within lookback period

Where checkedIndependent Health prescription history

Alternative processPrescriber may request prior authorization if history does not document insulin use within 108 days

Provider Actions, Prior Authorization, and Restrictions

Prior Authorization

Prior authorization required for new CGM starts (insulin users may be exempt at retail)

Prior authorization is required for members who are newly prescribed a therapeutic or non-therapeutic continuous glucose monitor (new starts). Members using insulin may obtain CGMs and supplies at network retail pharmacies without prior authorization when the patient's Independent Health prescription history documents concurrent or prior insulin use within the previous 108 days; otherwise the prescriber must request authorization through the standard authorization process. If authorization criteria are met, approval may be provided indefinitely.

Retail pharmacy no-PA access applies only when prescription history documents concurrent/prior insulin use within the previous 108 days.
Prescriber must submit standard authorization for members obtaining CGMs from a DME provider or when insulin use is not documented in prescription history.

Step Therapy

Coverage limited to preferred therapeutic CGMs

Coverage for therapeutic CGMs and supplies is limited to Independent Health’s preferred products: FreeStyle Libre, FreeStyle Libre 2, FreeStyle Libre 3, Dexcom G6, and Dexcom G7.

Preferred devices: FreeStyle Libre, FreeStyle Libre 2, FreeStyle Libre 3, Dexcom G6, Dexcom G7

Documentation Required

Authorization documentation and medical necessity criteria

Pharmacy Services may authorize coverage when the medical necessity criteria are met; prior authorization submissions must document a diagnosis of diabetes and either concurrent insulin use or a history of problematic hypoglycemia as specified in the criteria.

Documentation must show: diagnosis of diabetes; AND either insulin use OR history of problematic hypoglycemia (recurrent level 2 events or one level 3 event as defined).
Prescribers use the standard authorization process when prescription history does not document insulin use or when obtaining CGMs from a DME provider.

Denial Risk

Smartphone-only CGM displays without receiver/integration are not covered

CGM devices that solely display results on a smartphone and do not have a stand‑alone receiver or integration into an insulin infusion pump do not meet the definition of DME and will be denied as non‑covered (no benefit).

Such smartphone-only devices are excluded from DME coverage and considered not covered (no benefit).

Definitions

Therapeutic (non-adjunctive) CGM

DefinitionTherapeutic (non-adjunctive) CGM can be used as a replacement for fingerstick blood glucose testing for diabetes treatment decisions.

Insulin-dosing usePermitted to guide insulin dosing and other treatment decisions without additional fingerstick confirmation.

Coverage statusCovered when medical necessity criteria are met (see authorization criteria).

Preferred productsIndependent Health lists preferred therapeutic CGMs (e.g., FreeStyle Libre series, Dexcom G6/G7) for coverage limits.

Non-therapeutic (adjunctive) CGM

DefinitionNon-therapeutic (adjunctive) CGM cannot be used to make insulin-dosing decisions and must be used in conjunction with finger stick testing using a standard home glucose monitor.

Insulin-dosing useNot permitted for insulin dosing decisions—fingerstick confirmation required.

Coverage statusCovered when medical necessity criteria are met; supplies billed with adjunctive CGM HCPCS when appropriate.

Related HCPCSE2102 is the code for adjunctive (non-therapeutic) CGM or receiver.

Background

Continuous glucose monitoring (CGM) systems provide ongoing glucose measurements to support diabetes management. The policy distinguishes therapeutic (non-adjunctive) CGMs, which may be used as a replacement for fingerstick blood glucose testing for diabetes treatment decisions, from non-therapeutic (adjunctive) CGMs, which must be used in conjunction with fingerstick testing and cannot be used alone for insulin-dosing decisions. Coverage is provided for both types when other policy criteria are met, and certain products are designated as preferred for therapeutic use.