CurrentLouisiana Department of HealthPolicy 22-23

Reimbursement for Continuous Glucose Monitoring Devices

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This policy governs Louisiana Medicaid reimbursement for long-term continuous glucose monitoring devices through the durable medical equipment program and applies to fee-for-service and managed care claims.

Policy Summary

PayerLouisiana Department of Health

PolicyReimbursement for Continuous Glucose Monitoring Devices

Policy CodePolicy 22-23

Change TypeRevised coverage criteria

Effective DateAugust 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization and document that the beneficiary meets at least one eligibility criterion before providing long-term CGM coverage.

SourceLink

POLICY UPDATE CHANGES

Louisiana Medicaid changed the eligibility criteria for long-term continuous glucose monitoring devices.

Short-term continuous glucose monitors are not considered covered devices.

3Eligibility pathways for long-term CGM coverage

Every 6 monthsMinimum follow-up frequency

7, 10, or 14 daysPossible sensor lifespans

Monthly rate

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CurrentLouisiana Department of HealthPolicy 22-23

Reimbursement for Continuous Glucose Monitoring Devices

Customize your policy alerts

Sign up for Louisiana Department of Health Policy 22-23 alerts

Get alerted when Policy 22-23 changes without checking for updates manually.

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Policy Summary

PayerLouisiana Department of Health

PolicyReimbursement for Continuous Glucose Monitoring Devices

Policy CodePolicy 22-23

Change TypeRevised coverage criteria

Effective DateAugust 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization and document that the beneficiary meets at least one eligibility criterion before providing long-term CGM coverage.

SourceLink

POLICY UPDATE CHANGES

Louisiana Medicaid changed the eligibility criteria for long-term continuous glucose monitoring devices.

Short-term continuous glucose monitors are not considered covered devices.

3Eligibility pathways for long-term CGM coverage

Every 6 monthsMinimum follow-up frequency

7, 10, or 14 daysPossible sensor lifespans

Monthly rate

Long-Term CGM Coverage Criteria

Long-term CGM eligibility

Covered when at least one of the following eligibility criteria is met:

Eligibility criteria

Insulin-treated diabetes: Diagnosis of any type of diabetes with use of insulin more than two times daily.Insulin use >2 times daily
Hypoglycemia: Evidence of level 2 or level 3 hypoglycemia.Level 2 or level 3 hypoglycemia
Glycogen storage disease: Diagnosis of glycogen storage disease type 1a.Glycogen storage disease type 1a

Short-term continuous glucose monitors are not considered covered devices under Louisiana Medicaid. Coverage criteria in this policy apply to long-term CGM devices furnished through the durable medical equipment program.

CGM Medical Necessity

CGM medical necessity criteria

The beneficiary must meet at least one of the following eligibility criteria:

Medical necessity eligibility

Insulin-treated diabetes: Diagnosis of any type of diabetes with use of insulin more than two times daily.Insulin use >2 times daily
Hypoglycemia: Evidence of level 2 or level 3 hypoglycemia.Level 2 or level 3 hypoglycemia
Glycogen storage disease: Diagnosis of glycogen storage disease type 1a.Glycogen storage disease type 1a

Authorization and Coverage Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage of long-term continuous glucose monitoring (CGM) devices through the durable medical equipment program. The beneficiary must meet at least one eligibility criterion.

Diagnosis of any type of diabetes with insulin use more than two times daily.
Evidence of level 2 or level 3 hypoglycemia.
Diagnosis of glycogen storage disease type 1a.

Documentation Required

Prescription and Medical Necessity Documentation

CGM devices require a prescription and documentation supporting medical necessity. Beneficiaries receiving coverage must also attend regular follow-up visits with a healthcare provider at least every six months to assess ongoing benefits.

Prescription for the CGM device.

Required Documentation and Follow-Up

Documentation Required

Document medical necessity

Maintain documentation that supports the beneficiary’s medical need for the CGM device. Medical-necessity documentation is required for CGM coverage.

Documentation Required

Obtain a CGM prescription

Obtain a prescription for the CGM device. A prescription is required for CGM coverage.

Documentation Required

Schedule follow-up at least every six months

Ensure beneficiaries receiving CGM coverage attend regular follow-up visits with a healthcare provider at a minimum of every six months. These visits assess the ongoing benefits of coverage.

CGM Device Definitions

Long-term CGM device

Device typeA continuous glucose monitoring (CGM) device used on a long-term basis.

Coverage programCovered through the durable medical equipment program when applicable eligibility criteria and prior authorization requirements are met.

Coverage distinctionLong-term CGM devices are distinguished from short-term CGMs, which Louisiana Medicaid does not consider covered devices.

Short-term CGM

Device typeA continuous glucose monitor intended for short-term use.

Coverage statusLouisiana Medicaid will not consider short-term CGMs as a covered device.

Excluded Devices

Short-term continuous glucose monitoring devices are not covered by Louisiana Medicaid.

Policy Background

This policy governs Louisiana Medicaid coverage of long-term continuous glucose monitoring (CGM) devices through the durable medical equipment program. Effective for dates of service on or after August 1, 2022, coverage requires prior authorization and applies to beneficiaries with diabetes using insulin more than twice daily, documented level 2 or level 3 hypoglycemia, or glycogen storage disease type 1a. Beneficiaries receiving coverage must attend follow-up visits with a healthcare provider at least every six months to assess ongoing benefits.