CurrentMass General Brigham Health PlanPolicy N/A

Continuous Blood Glucose Monitors (CGM) — Coverage Criteria

Govern prior authorization, coverage criteria, limitations, and reauthorization requirements for continuous glucose monitors (Dexcom, FreeStyle Libre and similar CGMs) for plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyContinuous Blood Glucose Monitors (CGM) — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial updates to product list, new-to-plan criteria, non‑diabetes examples, and reauthorization clarification

Effective DateOct 15, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis and provider attestation that CGM data is reviewed and used to monitor or adjust the treatment plan.

SourceLink

POLICY UPDATE CHANGES

Added Simplera as a CGM that is not covered through pharmacy.

Added criteria for members who are new to the plan.

Updated criteria for non-diabetes hypoglycemia to list diagnoses as examples.

Updated reauthorization criteria to include improvement in hypoglycemic control as an option to demonstrate benefit from therapy.

12 monthsapproval duration

1/yrmonitor limit

1/90 daystransmitter limit

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Coverage Criteria for Continuous Glucose Monitors

inv-01: Initial Therapy - Diabetes Mellitus

Covered when ALL of the following are met

Initial coverage for diabetes mellitus

Insulin requirement or exceptions: Member has a paid claim or physician attestation requiring insulin administration or member is using an insulin pump; members not receiving insulin due to physical disability, visual impairment, cognitive impairment, or age <18 years may bypass this requirement
Additional clinical indications: One of: A1C not meeting documented treatment goal; history of hypoglycemic unawareness; frequent hypoglycemia (including nocturnal hypoglycemia); dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; use with a compatible insulin pump to achieve glycemic control; history of emergency room visit or hospitalization related to diabetic ketoacidosis or hypoglycemia; pregnancy

Notes: Members not receiving insulin due to physical disability, visual impairment, cognitive impairment, or age <18 years may bypass the insulin requirement

inv-02: Initial Therapy - Non-Diabetes Based Condition

Covered when ALL of the following are met

Non-diabetes based condition

Diagnosis: Member has a disorder resulting in frequent hypoglycemia (examples: seizure disorder, insulinoma, genetic condition causing hyperinsulinemia, post-surgical effects such as post-esophagectomy, post-fundoplication, post-gastrectomy, post-gastric bypass, post-sleeve gastrectomy)
Hypoglycemic risk: Documentation of hypoglycemic risk
Rationale for CGM use: Rationale for use of CGM instead of capillary blood glucose monitoring (examples: frequent or nocturnal hypoglycemia, history of hypoglycemic unawareness, limited dexterity, comorbid conditions impacting fingerstick testing such as Raynaud's or autism)
Past events:

inv-03: Continuation of Therapy

Requests for reauthorization will be approved when ALL of the following criteria are met

Reauthorization: Provider attestation that the member's CGM data has been reviewed and is being used to monitor or adjust the treatment plan

Demonstration of benefit: Documented improvement (including improvement in hypoglycemic control) or continued clinical need as evidenced by CGM data review

Replacements or coverage for continuous glucose monitoring devices will be excluded if the device is still under manufacturer warranty. Requests for replacement or reimbursement for devices that are lost, stolen, or damaged due to improper care, misuse, or neglect may be denied unless the member provides required proof (for stolen or damaged items this may include a police report, pictures, or corroborating statement).

The plan also excludes coverage for devices or device features that are used principally for convenience and are not medically necessary, and will not cover newer or upgraded models when the member already has a functioning model.

Device features that are intended principally for convenience rather than to meet a medical need are considered not medically necessary and are excluded from coverage.

Similarly, when a member already has a functioning model of a continuous glucose monitor, requests for newer or upgraded models are not medically necessary and will not be approved.

Product Families and Coding

Covered product families requiring PAmixedCovered

Dexcom products	Dexcom family of CGM devices (products requiring prior authorization)
FreeStyle Libre products	FreeStyle Libre family of CGM devices (products requiring prior authorization)
Simplera	Simplera listed as a CGM not covered through pharmacy

A1C — A1C not meeting documented treatment goal (exact target unspecified)

A1C criterionA1C value that does not meet the documented treatment goal (exact numeric target not specified in policy)

ContextIncluded as one of the clinical indications for initial CGM coverage in members with diabetes mellitus

Associated requirementsMember must have a diagnosis of diabetes mellitus and meet at least one additional criterion (e.g., insulin use or documented insulin requirement, hypoglycemic unawareness, frequent/nocturnal hypoglycemia, etc.)

Bypass noteMembers not receiving insulin due to physical disability, visual impairment, cognitive impairment, or age <18 years may bypass the insulin requirement while still using A1C criterion as an indication

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Dexcom and FreeStyle Libre products (and similar continuous glucose monitors). Authorization may be granted for members new to the plan who are currently receiving the requested CGM (excluding products obtained as samples or via manufacturer patient assistance programs).

Applies to Dexcom and FreeStyle Libre products and similar CGMs
Authorization may be granted for members new to the plan who are already receiving therapy (not applicable to samples or manufacturer patient assistance program supplies)

Step Therapy

No step therapy sequencing requirements are specified in this policy document.

Background on Continuous Glucose Monitors

Continuous glucose monitors (CGMs) are devices that measure glucose in the interstitial fluid at regular intervals to provide ongoing glucose values and trend information; they may be minimally invasive or noninvasive. CGMs are used to monitor glucose continuously and can support detection of hypoglycemia, hypoglycemic unawareness, and glycemic patterns that inform treatment adjustments.

CGMs are FDA-approved for patients with diabetes mellitus and may also be appropriate for non-diabetes conditions that cause frequent or severe hypoglycemia (for example, seizure disorder, insulinoma, genetic hyperinsulinemia, or post-surgical effects) when documentation supports the clinical need.

Definitions

Continuous Glucose Monitor (CGM) — Definition and key characteristics

DefinitionA continuous glucose monitor (CGM) is a minimally invasive or noninvasive device that measures interstitial glucose at set intervals (often via a small subcutaneous electrode) and provides real-time glucose values, trend information, and direction/rate of change.

Typical componentsSmall electrode/sensor placed under the skin and held by adhesive; wearable transmitter and receiver or compatible display device.

Use casesFDA-approved for patients with diabetes mellitus; may also be appropriate for non-diabetes conditions causing frequent/nocturnal hypoglycemia or hypoglycemic unawareness (e.g., seizure disorder, insulinoma, genetic hyperinsulinemia, post-surgical effects).

BenefitProvides continuous, real-time glucose data used to monitor glucose trends and inform treatment adjustments, including insulin therapy and hypoglycemia management.