CurrentKaiser PermanentePolicy 03-26
Continuous Glucose Monitor (CGM) for pediatric diabetes
Defines medical necessity criteria, indications, contraindications, supply allowances, and utilization management procedures for CGM devices (CPT/HCPCS A9276, A9277, A9278 / K0553, K0554 referenced) for pediatric members with diabetes in the Georgia Region.
Policy Summary
PayerKaiser Permanente
PolicyContinuous Glucose Monitor (CGM) for pediatric diabetes
Policy CodePolicy 03-26
Change TypeReviewed/Revised (no material change)
Effective DateJul 10, 2009
Next Review DateMar 14, 2025
Key ActionRequests for CGM devices should be forwarded to Quality Resource Management (QRM) for review under the member's DME benefit.
POLICY UPDATE CHANGES
Reviewed/Revised on 3/14/2025 with no explicit material change noted in document.
PediatricPopulation focus
DiabetesPrimary Diagnosis Group
6 moInitial sensor supply period
Coverage Summary
This policy defines medical necessity criteria for continuous glucose monitoring (CGM) in pediatric members with diabetes and is classified as covered_with_criteria. It focuses on CGM device coverage (HCPCS A9276, A9277, A9278; K0553, K0554 referenced) for patients under 18 years managed by pediatric endocrinology.