CurrentKaiser PermanentePolicy N/A

Continuous Glucose Monitoring System (CGMS) coverage

Defines clinical documentation and authorization requirements for initial and continued patient-use continuous glucose monitoring systems (CGMS) for Kaiser Permanente members; applies to requests originating from KP Endocrinology or contracted providers who routinely manage patients using CGMS.

Policy Summary

PayerKaiser Permanente

PolicyContinuous Glucose Monitoring System (CGMS) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAttach a medical record summary demonstrating the patient meets commercial or Medicare criteria and ensure requests come from Kaiser Permanente Endocrinology or a contracted provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial & Medicaredistinct benefit categories referenced

3+ injections/daycommercial insulin regimen threshold

<70 mg/dL; ≤54 mg/dLhypoglycemia thresholds referenced

Clinical Coverage Criteria for CGMS

General submission requirement

All requests must come from Kaiser Permanente Endocrinology or a Kaiser Permanente contracted provider whose practice routinely includes patients with diabetes using CGMS.

ALL of the following

Request originates from Kaiser Permanente Endocrinology or a Kaiser Permanente contracted provider whose practice routinely includes patients with diabetes using CGMS
Attach a summary statement of the medical record documentation that attests the patient meets the applicable criteria

Commercial coverage criteria — initial or continuation

Coverage granted when ALL of the following are met:

ALL of the following

Policy Summary

PayerKaiser Permanente

PolicyContinuous Glucose Monitoring System (CGMS) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAttach a medical record summary demonstrating the patient meets commercial or Medicare criteria and ensure requests come from Kaiser Permanente Endocrinology or a contracted provider.

SourceLink

On This Page

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AND ONE of the following is present

Medical record documentation of recurrent severe symptomatic hypoglycemia (blood glucose measurements less than 70 mg/dL) despite best practice management
Hypoglycemia threshold: < 70 mg/dL
Type 1 diabetes with significant glucose variability (blood glucose range from 70–300 mg/dL OR standard deviation of BG > 50 mg/dL)
Glucose variability threshold: BG range 70–300 mg/dL or SD > 50 mg/dL
Patient is pregnant and on multiple daily injections of insulin or using an insulin pump
Severe dexterity impairment
Severe vision impairment
Currently using an insulin pump requiring integration with CGM

Medicare coverage criteria — initial or continuation

Coverage granted when ALL of the following are met:

ALL of the following

Has a diagnosis of diabetes
Is on one or more daily administrations of insulin
If patient is on oral agents only, at least one of the following must be documented
- History of recurrent (more than one) blood glucose reading ≤ 54 mg/dL that persist despite multiple attempts to adjust medications/modify treatment plan
  Medicare hypoglycemia threshold: recurrent BG ≤ 54 mg/dL
- History of one blood glucose < 54 mg/dL characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
  Medicare hypoglycemia threshold: single BG < 54 mg/dL with altered mental/physical state requiring assistance

Authorization and Documentation Requirements

Prior Authorization

Authorization source requirement

All requests for patient-use continuous glucose monitoring systems (CGMS) must originate from Kaiser Permanente Endocrinology or a Kaiser Permanente contracted provider whose practice routinely includes patients with diabetes using CGMS.

Documentation Required

Medical record summary attachment

Attach a summary statement of the medical record documentation attesting the patient meets the applicable commercial or Medicare criteria.

Patient diagnosis of diabetes
Insulin regimen (e.g., 3 or more insulin injections per day or insulin infusion pump for commercial; 1 or more daily insulin administrations for Medicare)
Reasons the treatment regimen requires frequent adjustment based on glucose data
Documentation of hypoglycemia or glucose variability as applicable (commercial: recurrent symptomatic hypoglycemia < 70 mg/dL or type 1 with BG range 70–300 mg/dL or SD > 50 mg/dL; Medicare: recurrent BG ≤ 54 mg/dL despite adjustments or one BG < 54 mg/dL requiring third‑party assistance)

Documentation Required

Provider signature and contact

The healthcare provider managing the patient’s diabetes must print their name, sign and date the form, and provide phone and email contact information; fax the completed form and required documentation to Kaiser Permanente Review Services at 1-844-660-0717.

Documentation Required

Training and management assignment

Document who will provide patient education and training and who will be medically responsible for ongoing CGM management.

Identify the staff or program that will provide patient education and training
Identify the clinician responsible for ongoing CGM medical management

Key Clinical Thresholds and Defined Terms

Key thresholds for CGMS coverage

Commercial insulin intensity3 or more insulin injections per day or insulin infusion pump

Hypoglycemia threshold (commercial)Blood glucose < 70 mg/dL

Glucose variability (commercial)Blood glucose range 70–300 mg/dL OR standard deviation of BG > 50 mg/dL

Medicare hypoglycemia (oral agents)Recurrent BG ≤ 54 mg/dL despite attempts to adjust treatment OR one BG < 54 mg/dL with altered mental/physical state requiring third‑party assistance

Definitions

Starter kitInitial equipment package required for patients new to CGM; typically includes sensors and transmitter/reader as applicable (e.g., Medtronic start‑up kit, DexCom start‑up kit with transmitter for G6, FreeStyle Libre reader and sensors)

Recurrent severe symptomatic hypoglycemiaRepeated symptomatic low blood glucose events; commercial criteria reference blood glucose measurements < 70 mg/dL, Medicare criteria reference ≤ 54 mg/dL for clinically significant events

Clinical Context

Continuous glucose monitoring systems (CGMS) are wearable devices that provide frequent interstitial glucose measurements to support insulin dosing adjustments, detection of hypoglycemia, and management of glucose variability. CGMS starter kits and supplies referenced in this policy include vendor-specific start-up packages such as Medtronic, DexCom (including the G6 transmitter), and FreeStyle Libre systems and readers.

Payers typically require clinical documentation that demonstrates medical necessity for CGMS. For Kaiser Permanente coverage, all requests must originate from Kaiser Permanente Endocrinology or a Kaiser Permanente contracted provider whose practice routinely includes patients with diabetes, and the request must include a summary statement of the medical record documenting that the patient meets the applicable criteria.

Common justification elements the policy relies on are: insulin intensity (for commercial plans, 3 or more insulin injections per day or use of an insulin infusion pump), evidence of problematic or recurrent hypoglycemia (commercial threshold blood glucose < 70 mg/dL; Medicare references clinically significant events at or below 54 mg/dL), and clinically significant glucose variability (for type 1 diabetes, BG range 70–300 mg/dL or standard deviation of BG > 50 mg/dL).

The documentation package should also identify who will provide patient education and training and who will medically manage ongoing CGM use, and administrative requests may include initial starter kits for new users, annual reviews for continuation, or continuation requests for members new to Kaiser Permanente.

OpenPayer

Continuous Glucose Monitoring System (CGMS) coverage

Clinical Coverage Criteria for CGMS

Coding and Billing Notes

Authorization and Documentation Requirements

Key Clinical Thresholds and Defined Terms

Clinical Context

Policy Update Changes