CurrentKaiser PermanentePolicy N/A

Continuous Glucose Monitoring (CGM) for pediatric diabetes — Coverage Criteria

Criteria for medical necessity review and utilization management of continuous glucose monitoring devices for pediatric patients (<18 years) with diabetes within the Georgia region of Kaiser Permanente; intended for Quality Resource Management and Utilization Management staff and ordering pediatric endocrinologists.

Policy Summary

PayerKaiser Permanente

PolicyContinuous Glucose Monitoring (CGM) for pediatric diabetes — Coverage Criteria

Policy CodePolicy N/A

Change TypeReviewed/Revised

Effective DateJul 10, 2009

Next Review DateMar 14, 2025

Key ActionPediatric endocrinologist must request prior authorization with documentation of diagnosis, insulin regimen, recent follow-up, and planned supply use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

pediatricage group covered

Type 1 diabetesprimary diagnosis

A9276/A9277/A9278billing codes listed

1 transmitter + 6 monthssupply allowance

3/14/2025

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Coverage Criteria — Continuous Glucose Monitoring (Pediatric)

Initial CGM coverage - Pediatric

Covered when ALL of the following are met:

Patient and care team requirements: Member is less than 18 years of age; diagnosis of type I diabetes; followed by pediatric endocrinologist; using insulin pump or multiple daily injections (>=3/day); currently performs blood glucose monitoring as instructed to adjust insulin; has at least one in-person or virtual visit with an endocrinologist in the last 6–12 months with interim phone contact with a diabetes educator; request is from a pediatric endocrinologist.age <18

See [[chunk 4]] for details

Clinical indications: At least one of: hypoglycemia unawareness with hypoglycemia requiring assistance and/or glucagon administration or ER visit within the last 3 months; nocturnal hypoglycemia refractory to insulin dose changes; seizure associated with hypoglycemia (>=1 in last 6 months); difficulty achieving target A1C despite engaged family and close management over last 6 months; CGM needed to maintain at or below glucose goal.1 of listed indications

See [[chunk 5]] for enumerated indications

Complicated diabetes exception

Covered when ALL of the following are met for complicated diabetes:

Complicated Type I diabetes: Type I diabetes and complicated diabetes managed by an endocrinologist — CGM may be requested after the first endocrinology visit provided insulin regimen requirements are met (using insulin pump or >=3 injections per day).after first visit

See [[chunk 4]] (4.2.6)

Patients who are managed solely with oral diabetes medications are excluded from coverage for continuous glucose monitoring (CGM). Requests for CGM in members without an insulin regimen should be denied based on this exclusion.

An inability or unwillingness to use sensor CGM, as demonstrated by a supervised trial, is considered a contraindication and is a basis for denial. Providers should document the trial outcomes showing that the member could not or would not use the sensor CGM to support medical necessity determinations.

Coding and Supply Allowances

Listed CGM HCPCS CodesHCPCS

A9276	Continuous glucose monitor (CGM), professional, sensor; per day supply
A9277	Continuous glucose monitor (CGM), real-time, sensor
A9278	Continuous glucose monitor (CGM), transmitter

Referenced K-codes (billing interactions)HCPCS

K0553	CGM supplies allowance (associated supply allowance)
K0554	CGM device

inv-07: Sensor supply interval

Supply allowanceOne transmitter/receiver per member plus sensors supplied monthly for 6 months (review at month 5 prior to 6-month reauthorization).

Sensor intervalSensors dispensed on a monthly basis for a 6-month initial period.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization required — pediatric endocrinologist must request

Prior authorization is required for CGM devices for pediatric members and the request should be submitted by the pediatric endocrinologist. Authorization must document the diagnosis, insulin regimen, recent endocrinology follow-up, and indication; supplies are authorized as one transmitter/receiver with sensors supplied monthly for 6 months and reauthorization review at month 5 prior to 6-month reauthorization.

Request must come from a pediatric endocrinologist (4.2.5).
Document diagnosis of type I diabetes and insulin regimen (pump or ≥3 injections/day) (4.2.1, 4.2.2).
One transmitter/receiver per member and sensors supplied monthly for 6 months; review at month 5 before reauthorization (11:8.2, 8.2.1).

Denial Risk

Trial demonstrating inability/unwillingness may be required

A trial demonstrating inability or unwillingness to use sensor CGM may be required and inability or unwillingness shown by such a trial is a contraindication and basis for denial.

Background and Rationale

Type 1 diabetes in children requires chronic exogenous insulin and frequent glucose monitoring. Continuous glucose monitoring (CGM) systems detect glucose trends and patterns over days, provide alarms for hypo- and hyperglycemia, and can improve management compared with fingerstick self-monitoring of blood glucose, particularly for nocturnal or rapidly fluctuating glucose. Real-time CGM devices measure and transmit glucose values at frequent intervals (for example, every five minutes) and provide active alerts, while intermittently scanned (flash) CGM record frequent measurements but may require periodic scanning to retain data.

Definitions — CGM Types

inv-13: real-time CGM

DefinitionReal-time CGM devices measure and transmit glucose values at frequent intervals (e.g., every 5 minutes) and provide real-time alerts/alarms for hypoglycemia and hyperglycemia to enable timely intervention.

Alarms & sharingDevices alert for hypo- or hyperglycemia and can securely share glucose data in real time with clinicians or caregivers via mobile apps.

Calibration & BGMRequirements for confirmatory fingerstick glucose measurements vary by device; some are factory calibrated while others may require periodic BGM for calibration or during sensor warm-up and rapid glucose changes.

inv-14: flash CGM

DefinitionIntermittently scanned (flash) CGM measures glucose every minute, records measurements every 15 minutes, and typically must be scanned at least every 8 hours to retain data.

Wear time & data retention

Revision History

2009-07-10Effective date

Policy became effective for the Georgia Region (criteria number No. 03-26).

2025-03-14ReviewLatest

Policy most recently reviewed/revised (last revision date recorded).