CurrentLouisiana Department of HealthPolicy 18-18

Reimbursement for Continuous Glucose Monitoring Devices (CGM)

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This policy governs Louisiana Medicaid reimbursement for long-term continuous glucose monitoring devices through the durable medical equipment program. Coverage applies to eligible beneficiaries who obtain prior authorization and meet specified diabetes-related medical necessity criteria.

Policy Summary

PayerLouisiana Department of Health

PolicyReimbursement for Continuous Glucose Monitoring Devices (CGM)

Policy CodePolicy 18-18

Change TypeAdded coverage

Effective DateJanuary 1, 2019

Next Review DateNot specified

Key ActionPrior authorization is required for reimbursement of long-term continuous glucose monitoring devices through the durable medical equipment program.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2019, Louisiana Medicaid began reimbursing long-term continuous glucose monitoring devices through the durable medical equipment program.

Jan. 1, 2019Effective date for reimbursement

RequiredPrior authorization for long-term CGM devices

2Alternative eligibility pathways

<50 mg/dLGlucose threshold for severe hypoglycemia criterion

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CurrentLouisiana Department of HealthPolicy 18-18

Reimbursement for Continuous Glucose Monitoring Devices (CGM)

Customize your policy alerts

Sign up for Louisiana Department of Health Policy 18-18 alerts

Get alerted when Policy 18-18 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerLouisiana Department of Health

PolicyReimbursement for Continuous Glucose Monitoring Devices (CGM)

Policy CodePolicy 18-18

Change TypeAdded coverage

Effective DateJanuary 1, 2019

Next Review DateNot specified

Key ActionPrior authorization is required for reimbursement of long-term continuous glucose monitoring devices through the durable medical equipment program.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2019, Louisiana Medicaid began reimbursing long-term continuous glucose monitoring devices through the durable medical equipment program.

Jan. 1, 2019Effective date for reimbursement

RequiredPrior authorization for long-term CGM devices

2Alternative eligibility pathways

<50 mg/dLGlucose threshold for severe hypoglycemia criterion

Coverage Criteria

Long-term CGM eligibility

Covered when prior authorization is obtained and at least one eligibility pathway is met.

Eligibility pathway
- Type 1 diabetes with severe hypoglycemia risk: Diagnosis of type 1 diabetes with recurrent, unexplained, severe hypoglycemia or impaired hypoglycemia awareness that puts the recipient at risk.Glucose levels less than 50 milligrams per deciliter for severe hypoglycemia
- Pregnancy with poorly controlled type 1 diabetes: The recipient is pregnant with poorly controlled type 1 diabetes evidenced by recurrent, unexplained hypoglycemic episodes, hypoglycemic unawareness, postprandial hyperglycemia, or recurrent diabetic ketoacidosis.

Short-term continuous glucose monitors (CGMs) are not considered covered devices under this policy. Coverage is limited to long-term CGM devices reimbursed through the durable medical equipment program when prior authorization is obtained and applicable eligibility criteria are met.

Coding and Clinical Thresholds

Severe hypoglycemia glucose level

ThresholdLess than 50 milligrams per deciliter

Provider Actions and Authorization

Prior Authorization

Obtain prior authorization for long-term CGM

Obtain prior authorization before seeking reimbursement for a long-term continuous glucose monitoring (CGM) device through the durable medical equipment (DME) program.

Denial Risk

Meet authorization and coverage requirements

The request may be denied if prior authorization is not obtained, the beneficiary does not meet at least one eligibility pathway, or the requested device is a short-term CGM.

Type 1 diabetes with recurrent, unexplained, severe hypoglycemia—glucose levels less than 50 milligrams per deciliter—or impaired hypoglycemia awareness that puts the recipient at risk.
Pregnancy with poorly controlled type 1 diabetes evidenced by recurrent, unexplained hypoglycemic episodes, hypoglycemic unawareness, postprandial hyperglycemia, or recurrent diabetic ketoacidosis.

Policy Background

This policy establishes Louisiana Medicaid reimbursement for long-term continuous glucose monitoring (CGM) devices through the durable medical equipment program. It addresses beneficiaries with type 1 diabetes who have recurrent, unexplained severe hypoglycemia—defined as glucose levels less than 50 milligrams per deciliter—or impaired hypoglycemia awareness that places them at risk. It also addresses pregnant recipients with poorly controlled type 1 diabetes, including recurrent hypoglycemia, hypoglycemia unawareness, postprandial hyperglycemia, or recurrent diabetic ketoacidosis.

Definitions

Long-term CGM

DefinitionA continuous glucose monitoring device intended for ongoing or long-term glucose monitoring.

Short-term CGM

DefinitionA continuous glucose monitoring device that is not intended for long-term use.

Coverage statusNot considered a covered device under this policy.

Severe hypoglycemia

DefinitionGlucose levels less than 50 milligrams per deciliter.

Medical Necessity Eligibility

Medical necessity eligibility

The beneficiary must meet one of the following eligibility criteria.

CGM medical necessity pathways

Type 1 diabetes with severe hypoglycemia risk: Diagnosis of type 1 diabetes with recurrent, unexplained, severe hypoglycemia or impaired hypoglycemia awareness that puts the recipient at risk.Glucose levels less than 50 milligrams per deciliter for severe hypoglycemia
Pregnant recipient with poorly controlled type 1 diabetes: Pregnancy with poorly controlled type 1 diabetes evidenced by recurrent, unexplained hypoglycemic episodes, hypoglycemic unawareness, postprandial hyperglycemia, or recurrent diabetic ketoacidosis.

Not Covered

Short-term continuous glucose monitors are not covered by Louisiana Medicaid under this policy.