ModifiedKaiser PermanentePolicy N/A

Continuous Glucose Monitor (CGM) clinical review criteria

Kaiser Permanente Clinical Review Criteria governing medical necessity review and authorization of patient-use continuous glucose monitoring systems for members of Kaiser Foundation Health Plan of Washington and its Options plan; intended for use by providers and internal reviewers.

Policy Summary

PayerKaiser Permanente

PolicyContinuous Glucose Monitor (CGM) clinical review criteria

Policy CodePolicy N/A

Change TypeRevisions to criteria and codingbroadened ordering providers

Effective DateN/A

Next Review DateMar 1, 2026

Key ActionComplete the Request for Approval of Patient-Use Continuous Glucose Monitoring System form and submit required documentation (notes, labs, home logs/CGM printouts) to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

MPC approved updates to the Continuous Glucose Monitoring (CGM) policy with an effective date of March 1, 2026.

MPC approved changes to allow providers managing a member's diabetes (including primary care, internal medicine, etc.) to place CGM orders effective 01/01/2024.

Updated applicable codes; added HCPCS codes A4239 and E2103 effective 1/1/2023 and removed reference to K0554 replaced by E2103.

Updated CGM criteria to remove the 4x/day blood glucose checks and add indications for patients with dexterity or visual impairments (effective 09/01/2022).

ListDocumentation requirements

KP-0126MCG reference

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Coverage Criteria and Determinations

Overall coverage determination process

Covered when ALL of the following are met:

Medical necessity support: Provider must submit required documentation (last 6 months of clinical notes, last 6 months of laboratory work, and last 1–2 months of home monitoring logs or CGM printouts) and complete the Request for Approval of Patient‑Use Continuous Glucose Monitoring System order form.

Kaiser Permanente uses MCG (KP‑0126) for non‑Medicare members; Medicare determinations reference applicable NCDs/LCDs and billing articles.

Coverage by payer and device type

Coverage is contingent on meeting the applicable policy statements; payer and device type affect coverage stance and applicable codes.

Medicare - non‑implantable CGM: Considered medically necessary when the applicable Medicare policy statements and coverage criteria are met.

Applicable HCPCS codes: A4238, A4239, E2102, E2103.

Non‑Medicare - non‑implantable CGM: Considered medically necessary when the applicable Kaiser Permanente/MCG (KP‑0126) criteria are met.

Applicable HCPCS codes: A4238, A4239, A9276, A9277, A9278, E2102, E2103.

Implantable CGM - Medicare: Considered medically necessary when the applicable Medicare policy statements and coverage criteria are met.

Applicable CPT procedure codes: 0446T, 0447T, 0448T.

Implantable CGM - Non‑Medicare: Considered not medically necessary.

Non‑Medicare members: I‑CGM insertion/removal codes (0446T‑0448T) are considered not medically necessary and may be denied.

Continuous glucose monitor (CGM) readings are intended to be used as an adjunct to self‑monitoring of blood glucose (SMBG) and not as the sole basis for therapeutic decisions. CGM data provide frequent interstitial glucose values and trends but have known limitations — including a lag time relative to blood glucose during rapid changes and potential calibration or sensor issues — that require confirmatory testing with a standard blood glucose meter before initiating treatment changes.Any actionable hypoglycemia or hyperglycemia reading should be verified by SMBG prior to treatment.

Real‑time CGM devices can generate alarms for high or low glucose thresholds and provide trend information to inform care. Because effective use requires patient and provider interpretation of frequent data, patients must be able to perform SMBG, understand device limitations, and be trained to respond to alarms and trends; providers should ensure confirmatory SMBG and clinical correlation before altering insulin or other therapies based solely on CGM values.

For non‑Medicare members, implantable continuous glucose monitors (I‑CGM) are considered not medically necessary. The policy lists the implantable device procedure codes (CPT 0446T–0448T) under the non‑Medicare not‑medically‑necessary stance and such requests for implantable sensors may be denied for non‑Medicare members.

Kaiser's evidence reviews over time found that early and mid‑2000s studies were generally small and methodologically limited, and systematic MTAC reviews repeatedly concluded that evidence was insufficient to meet Kaiser’s Medical Technology Assessment Criteria for broad coverage. Multiple MTAC reviews (2001–2010 and subsequently) noted limited sample sizes, few randomized trials, and uncertainties about long‑term patient‑oriented outcomes such as hospitalizations, ER visits, and diabetic complications.

Some randomized and controlled trials showed improvements in intermediate measures (for example, time in target range or reductions in HbA1c in selected continuous users), and accuracy studies demonstrated many paired sensor‑SMBG values falling in clinically acceptable zones. However, MTAC and subsequent evidence summaries emphasized lingering concerns including the 15–30‑minute lag between interstitial and blood glucose during rapid changes, variable device performance across studies, and insufficient evidence of consistent, durable benefits on major clinical outcomes to support unrestricted coverage.

Restating the policy position for clarity: Implantable continuous glucose monitors (I‑CGM) are not considered medically necessary for non‑Medicare members. The policy specifically references the implantable CGM procedure codes 0446T, 0447T, and 0448T in the non‑Medicare not medically necessary listing.

Coding and Billing

Medicare coverage and billing referencesmixed

40.2	Home Blood Glucose Monitors (NCD)
L33822	Glucose Monitors (LCD)
L38657	Implantable Continuous Glucose Monitors (I-CGM) (LCD)
A52464	Glucose Monitor - Policy Article (Local Coverage Article)
A58133	Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (Article)

Medicare - Considered Medically Necessary codesHCPCSCovered

A4238	Supply allowance for adjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
A4239	Supply allowance for nonadjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
E2102	Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver.
E2103	Nonadjunctive, nonimplanted continuous glucose monitor (CGM) or receiver.

Non-Medicare - Considered Medically Necessary codes (non-implantable)HCPCSCovered

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 nonadjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
A9276	Sensor; invasive (e.g., subcutaneous), disposable, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM), one unit = 1 day supply.
A9277	Transmitter; external, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM).
A9278	Receiver (monitor); external, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM).
E2102	Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver.
E2103	Nonadjunctive, nonimplanted continuous glucose monitor (CGM) or receiver.

Implantable CGM procedure codesCPT

0446T	Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training.
0447T	Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision.
0448T	Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation.

Sensor day supply — mapping

Billing unit for sensor (A9276)A9276 — Sensor (invasive, disposable) — one unit = 1 day supply.

Monthly supply codes (context)A4238/A4239 — supply allowance for adjunctive/nonadjunctive nonimplanted CGM; 1 month supply = 1 unit of service.

Other sensor-related codesA9277 — transmitter (external); A9278 — receiver (monitor).

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required and Criteria Source

Prior authorization is required for patient-use continuous glucose monitoring systems (CGM). Providers must complete the Request for Approval of Patient-Use Continuous Glucose Monitoring System (CGMS) order form and submit it as the source documentation for prior authorization requests.

Complete and submit the CGMS Request for Approval order form with the prior authorization request
Kaiser Permanente uses proprietary MCG (KP-0126 03012026) guideline for Non‑Medicare medical necessity determinations; providers may request the specific criteria used for an individual case

Prior Authorization

Prior Authorization for CGM Devices and Supplies

Prior authorization is required for CGM devices and supplies. Medical necessity determinations follow the applicable policy statements and code-specific guidance. Supply HCPCS/CPT codes and unit-month mapping must be used when submitting claims.

A4238/A4239: supply allowance for adjunctive/nonadjunctive nonimplanted CGM — 1 month supply = 1 unit
A9276: sensor (one unit = 1 day supply); A9277: transmitter; A9278: receiver

Background and Rationale

Diabetes management requires frequent glucose assessment to reduce risks of acute and long‑term complications. Traditional self‑monitoring of blood glucose (SMBG) and periodic HbA1c testing provide essential but intermittent information; CGM systems were developed to give a more complete, continuous picture of interstitial glucose levels and trends by measuring glucose every 1–5 minutes.

CGM devices may help motivated patients and care teams identify trends, detect unrecognized hypoglycemia, and guide therapy adjustments when used appropriately. However, CGM has limitations — including sensor wear‑time constraints, potential skin issues, calibration needs, and physiologic lag between interstitial and blood glucose during rapid changes — and therefore CGM data must be integrated with SMBG and clinical context when making treatment decisions.

Definitions

Continuous Glucose Monitoring System (CGMS) — components and sensor wear durations

Core componentsDisposable short-term subcutaneous glucose sensor, reusable transmitter, and a receiver that displays glucose values and trends.

Sensor wear durations (device examples)Typical sensor wear: Guardian RT — 3 days; MiniMed/Paradigm real-time systems — up to 3 days; FreeStyle Navigator — 5 days; DexCom Seven — 7 days.

Sampling frequencyDevices measure interstitial glucose frequently (measurements every 10 seconds aggregated to values every 1–5 minutes).

Real-time vs retrospective CGM — distinction and clinical use

Real-time CGMProvides continuous glucose values to the patient/receiver in near real time and can alarm for high/low thresholds; data viewed immediately to guide patient awareness.

Retrospective CGM

Revision History and Policy Changes

2025-10-07MPC approvalLatest

MPC approved updates to the Continuous Glucose Monitoring (CGM) policy (requires 60-day notice; effective date March 1, 2026).

2023-08-08MPC approval

MPC approved changes to allow providers who manage a member's diabetes (including primary care, internal medicine, etc.) to place CGM orders to reduce burden on Diabetes Population care nurses (requires 60-day notice; effective date January 1, 2024).

2023-03-13

Policy Summary

PayerKaiser Permanente

PolicyContinuous Glucose Monitor (CGM) clinical review criteria

Policy CodePolicy N/A

Change TypeRevisions to criteria and codingbroadened ordering providers

Effective DateN/A

Next Review DateMar 1, 2026

SourceLink

On This Page

Prior Authorization

Insulin Pump Authorization Linkage

When CGM is being requested for use with an insulin infusion pump, authorization of the pump (HCPCS E0787 or E0784 + E2103 for Medicare) will only be granted if the patient meets both the CGM criteria in this policy and all criteria in the Insulin Pump clinical review criteria (including that the current device is no longer under warranty).

Pump authorization requires meeting CGM criteria AND Insulin Pump clinical review criteria
Ensure documentation of current device warranty status when applicable

Note

Policy Revisions Affecting Provider Actions

Policy revision history has impacted provider requirements over time (for example, removal of the 4x/day SMBG requirement and expansion of ordering privileges to providers managing members' diabetes). Providers should review current criteria and be aware of operational changes that affect prior authorization and ordering workflows.

Notable change: removal of 4x/day blood glucose checks requirement (effective 09/01/2022)
Providers managing a member's diabetes (including primary care/Internal Medicine) allowed to place orders (effective 01/01/2024)
Codes and code descriptions have been updated periodically; verify current applicable codes before submission

Documentation Required

Documentation Required to Support Medical Necessity

Required documentation to support medical necessity must be provided with the prior authorization request. Incomplete documentation may result in denial or delay.

Last 6 months of clinical notes from the requesting provider and/or specialist (endocrinology, primary care)
Last 6 months of laboratory work
Last 1–2 months of legible home monitoring logs or a printout of CGM results

Billing Rule

Billing Instructions for Supplies and Accessories

Supplies and accessories must be billed using the listed HCPCS/CPT codes and follow the stated unit-month mapping. Use the specified supply codes for adjunctive vs nonadjunctive devices and the daily sensor unit mapping where applicable.

A4238: supply allowance for adjunctive nonimplanted CGM — 1 month = 1 unit
A4239: supply allowance for nonadjunctive nonimplanted CGM — 1 month = 1 unit
A9276: sensor (one unit = 1 day supply) — bill daily units accordingly
Bill transmitters (A9277) and receivers (A9278) using the listed codes; E2102/E2103 for adjunctive/nonadjunctive receivers

Note

Use and Scope of Clinical Review Criteria

Use of the Kaiser Permanente Clinical Review Criteria and, for Non‑Medicare members, the proprietary MCG guideline (KP-0126 03012026) is required for medical necessity determinations. These criteria apply only to Kaiser Foundation Health Plan of Washington and its Options plan.

Clinical Review Criteria are for internal use and apply only to Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.
For Non‑Medicare members, Kaiser Permanente uses the MCG guideline KP-0126 03012026 — providers may request the specific criteria used for an individual utilization management decision

Denial Risk

Non‑Medicare Coverage Note — Implantable CGM Denial Risk

Implantable interstitial continuous glucose monitoring (I-CGM) devices and related procedures (e.g., codes 0446T, 0447T, 0448T) are considered not medically necessary for Non‑Medicare members and may be denied.

Non‑Medicare determinations: implantable CGM procedures and devices listed as not medically necessary
Requests for implantable CGM for non‑Medicare members risk denial as not medically necessary

Non-implanted CGM systems — description and adjunctive status

Non-implanted CGM componentsSensors (disposable short-term subcutaneous), transmitters (reusable external), and receivers/monitors (pager-size or integrated receivers).

Adjunctive vs nonadjunctiveAdjunctive CGM (billing: A4238 or E2102) requires verification by SMBG before making treatment decisions; nonadjunctive CGM (billing: A4239 or E2103) may be used to make treatment decisions per device labeling.

Supply billing conventionsSupply allowance codes (A4238/A4239) represent 1 month supply = 1 unit; sensors billed with per-day units (A9276 = 1 day supply).

Implantable Continuous Glucose Monitor (I-CGM) — definition and procedure codes

Definition of I-CGMImplantable Continuous Glucose Monitor (I-CGM) — an interstitial glucose sensor implanted subcutaneously requiring procedural insertion/removal.

Procedural CPT codes0446T — creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor (includes activation and training).

Removal and replacement codes0447T — removal of implantable interstitial glucose sensor via incision; 0448T — removal with creation of new pocket and insertion of new implantable sensor (includes activation).