CurrentMass General Brigham Health PlanPolicy N/A

Continuous Blood Glucose Monitors (CGM) — Coverage Criteria

Policy governing prior authorization and coverage criteria for pharmacy-benefit continuous glucose monitors (Dexcom and FreeStyle Libre products and similar) for Commercial/Exchange members of Mass General Brigham Health Plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicyContinuous Blood Glucose Monitors (CGM) — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial revisions and clarifications

Effective DateOct 15, 2025

Next Review DateN/A

Key ActionSubmit prior authorization for covered CGM products for Commercial/Exchange members; authorization may be granted for members new to the plan who are currently receiving the requested CGM (excluding samples or manufacturer assistance) or when specified clinical criteria are met.

SourceLink

POLICY UPDATE CHANGES

Added Simplera as a CGM that is not covered through pharmacy and added criteria for members who are new to the plan.

Moved off-label criteria from the Appendix into the Coverage Guidelines section and updated reauthorization criteria to include improvement in hypoglycemic control as demonstration of benefit.

Authorization may be granted for members new to the plan who are currently receiving the requested CGM, excluding samples or manufacturer patient assistance programs.

12 monthsInitial and reauthorization approval length

1/yrMonitor quantity limit

1/90 days

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Transmitter quantity limit

3/monthSensor quantity limit

Commercial/ExchangePlan applicability

Coverage Criteria for CGMs

Initial therapy — Diabetes Mellitus

Covered when ALL of the following are met for diabetes mellitus:

Diabetes diagnosis and insulin use: Member has a diagnosis of diabetes mellitus AND 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 the insulin requirement).

From Coverage Guidelines

At least one clinical indication: At least ONE of the following: (a) A1C ≥7% or value that does not meet documented target treatment goal; (b) frequent hypoglycemia (including nocturnal hypoglycemia); (c) history of hypoglycemic unawareness; (d) dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; (e) history of emergency room visit or hospitalization related to diabetic ketoacidosis or hypoglycemia; (f) use with a compatible insulin pump to achieve glycemic control; (g) pregnancy.

Enumerated options a–g

Initial therapy — Non-diabetes-based conditions

Covered when ALL of the following are met for non-diabetes-based hypoglycemia disorders:

Disorder causing frequent hypoglycemia: Member has a disorder resulting in frequent hypoglycemia (examples include seizure disorder, insulinoma, genetic condition causing hyperinsulinemia, or post-surgical conditions such as post esophagectomy, post fundoplication, post gastrectomy, post gastric bypass, or post sleeve gastrectomy).

Diagnosis examples provided

Prescriber documentation: Prescriber submits documentation of all of the following: (a) hypoglycemic risk; (b) past hypoglycemic events; and (c) rationale for use of CGM instead of capillary blood glucose monitoring (e.g., frequent or nocturnal hypoglycemia, hypoglycemic unawareness, limited dexterity, or comorbid conditions that impact ability to perform finger sticks).

Required documentation

Continuation of Therapy

Reauthorization approved when ALL of the following are met:

Clinical benefit or stability: Improvement in diabetic or hypoglycemic control or relative stability (examples include provider attestation or demonstrated A1C improvement).

Evidence acceptable includes provider attestation or A1C

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

Required for continuation

Replacement or repair requests for home long-term continuous glucose monitors (CGMs) are not covered in the following situations: when the device is still under the manufacturer's warranty; when the device is lost, stolen, or damaged due to improper care, misuse, or neglect (the plan may require proof such as a police report, photographs, or a corroborating statement); or when the member already has a functioning model and a newer or upgraded model is not medically necessary.

Devices or device features that are principally intended for convenience and do not provide a medical benefit are considered not medically necessary and are excluded from coverage.

Covered Products and Clinical Thresholds

Covered CGM products (examples listed)mixed

Dexcom	Dexcom Products
FreeStyle Libre	FreeStyle Libre Products

inv-07: A1C — threshold/target info (>= 7% or does not meet documented target treatment goal)

A1C thresholdA1C ≥ 7% or a value that does not meet the member's documented target treatment goal

Context of useOne of several qualifying clinical indications for initial CGM coverage in members with diabetes mellitus

Documentation noteProvider must document A1C value or documented target treatment goal in the prior authorization request

inv-08: Fasting blood sugar (Dawn phenomenon) — frequently exceeding 200 mg/dL

Fasting blood sugar thresholdDawn phenomenon defined as fasting blood sugars frequently exceeding 200 mg/dL

Clinical roleListed as one of the qualifying indications for initial CGM coverage in diabetes mellitus

Provider Requirements and Billing Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for covered CGM products for Commercial/Exchange members; authorization may be granted for members new to the plan who are currently receiving the requested CGM (exclusions apply).

Affects Commercial/Exchange members
Authorization may be granted for members new to the plan who are currently receiving the requested CGM (exclusions apply)

Step Therapy

No step therapy requirements are specified in this policy.

Documentation Required

Non-Diabetes Documentation

Background

Continuous glucose monitors (CGMs) provide near-continuous measurement of interstitial glucose, delivering real-time glucose values along with trend and rate-of-change information to inform glucose management. CGMs are FDA-approved for use in diabetes mellitus and may also be appropriate for certain conditions that cause frequent hypoglycemia or hypoglycemic unawareness (for example, seizure disorder, insulinoma, genetic hyperinsulinemia, or post-surgical conditions).

Definitions

inv-15: Continuous glucose monitor (CGM) — definition of device, minimally invasive or noninvasive, measures glucose at set intervals, provides real-time values and trend data.

DefinitionMinimally invasive or noninvasive device that measures glucose at set intervals (24 hours a day) using a small electrode placed under the skin and adhesive

Data providedGenerates real-time glucose values, direction, and rate-of-change (trend) data

Measurement mediumMeasures interstitial glucose translated into glucose measurements recorded continuously

Regulatory noteCGMs are FDA-approved for patients with a diagnosis of diabetes mellitus, though may be appropriate for some non-diabetes conditions causing frequent hypoglycemia

Policy Summary

PayerMass General Brigham Health Plan

PolicyContinuous Blood Glucose Monitors (CGM) — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial revisions and clarifications

Effective DateOct 15, 2025

Next Review DateN/A

SourceLink

On This Page

Provider documentationDocument frequency and values of fasting blood sugars to support PA request

For non-diabetes-based conditions prescriber must submit documentation supporting hypoglycemic risk, past hypoglycemic events, and rationale for CGM use instead of capillary blood glucose monitoring (e.g., frequent or nocturnal hypoglycemia, hypoglycemic unawareness, limited dexterity, or comorbid conditions that impact finger‑prick testing). Examples of qualifying disorders include seizure disorder, insulinoma, genetic hyperinsulinemia, or post‑surgical conditions (post esophagectomy, fundoplication, gastrectomy, gastric bypass, sleeve gastrectomy).

Documentation must include: a) hypoglycemic risk; b) past hypoglycemic events; c) rationale for CGM over capillary testing
Qualifying diagnoses include seizure disorder, insulinoma, genetic hyperinsulinemia, and certain post‑surgical conditions

Documentation Required

Reauthorization Documentation

Requests for reauthorization require evidence of benefit and ongoing clinical oversight: improvement or relative stability in diabetic/hypoglycemic control (provider attestation or A1C improvement may be used) and provider attestation that CGM data has been reviewed and is being used to monitor or adjust the treatment plan.

Provider attestation that CGM data has been reviewed and is used to guide treatment
Evidence of improvement or relative stability in control (e.g., A1C improvement or provider attestation)

Denial Risk

Replacement/Repair Denial Triggers

Requests for replacement or repair may be denied if the device is still under manufacturer warranty; if loss/theft/damage is due to misuse, neglect, or improper care (the plan may require proof such as a police report or photos); if the member has a functioning model and a newer/upgraded model is not medically necessary; or when device features are principally for convenience and not medically necessary.

Denial triggers: device under manufacturer warranty; loss/theft/damage due to misuse/neglect (proof may be required); functioning existing model and upgrade not medically necessary
Convenience features not medically necessary are excluded