Continuous Glucose Monitoring (CGM)
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Defines medical necessity, coverage criteria, prior authorization information, and covered CPT/HCPCS codes for FDA‑approved continuous glucose monitoring systems and related supplies for Moda Health Plan members.
Updated CGM description, removed age limits, and added requirements for implantable CGM and its continued usage.
Added requirement: 'Requests for ongoing diabetic supplies related to CGM will be covered with documentation from the ordering provider that the member is compliant with treatment.'
Added requirements for implantable CGM including age ≥18, meeting long-term CGM criteria, FDA approval, and clinical need documentation (e.g., inability to tolerate transcutaneous sensors).
Coverage Criteria for Continuous Glucose Monitoring
Short-term diagnostic CGM coverage
Covered when ANY of the following short-term diagnostic indications are met (device use 72 hours to one week):
Any one of these meets short-term coverage.
Long-term therapeutic CGM coverage
Covered for long-term therapeutic use when ONE of the following is met:
One of these conditions suffices for long-term coverage.
Pregnancy
Covered/considered during pregnancy:
Provider clinical judgment and documentation required.
Continuation/Renewal criteria
Continuation of coverage is considered when ALL of the following are met:
All three required for continued coverage.
Implantable CGM coverage
Implantable CGM (e.g., Eversense) is considered medically necessary when ALL of the following are met:
All conditions must be met for implantable CGM coverage.
The GlucoWatch, a device that measures interstitial glucose levels beyond three days, is considered experimental/investigational and is not covered by the plan.
Software required solely to download CGM data from the device to a computer for further management is considered a convenience item and is not medically necessary.
Combination devices that pair a blood glucose monitor with a cellular telephone or other devices not specifically indicated for diabetes management are considered convenience items and are not medically necessary.
Where applicable, coverage is governed by Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Compliance with those Medicare policies may limit or define plan coverage to the specifics of the applicable NCD/LCD.
In summary, use of the GlucoWatch and certain convenience items (download-only software and combination devices not intended specifically for diabetes management) are designated as not medically necessary or investigational and will not be covered.
Billing Codes and Diagnosis Coding
| 95249 | Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording. |
| 95250 | Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout recording. |
| 95251 | Analysis, interpretation and report; training, removal of sensor, and printout recording. |
| A4238 | Supply allowance for adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply. |
| A4239 | Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply. |
| S1031 | Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor. |
| 0447T | Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training. |
| 0448T | Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation. |
| E2102 | Adjunctive, non-implanted continuous glucose monitor or receiver. |
| E2103 | Non-adjunctive, non-implanted continuous glucose monitor or receiver. |
| No codes listed |
| E08.00 | Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC). |
| E08.01 | Diabetes mellitus due to underlying condition with hyperosmolarity with coma. |
| E08.10 | Diabetes mellitus due to underlying condition with ketoacidosis. |
| E08.00 | Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC). |
| E08.01 | Diabetes mellitus due to underlying condition with hyperosmolarity with coma. |
| E08.10-E08.11 | Diabetes mellitus due to underlying condition with ketoacidosis. |
| E08.22 | Diabetes mellitus due to underlying condition with diabetic nephropathy (diabetic chronic kidney disease). |
| E08.29 | Diabetes mellitus due to underlying condition with other diabetic kidney complication. |
| E08.311-E08.319 | Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy. |
| E08.3211-E08.3219 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy. |
| E08.3291-E08.3299 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema. |
| E08.3311-E08.3319 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema. |
| E08.3391-E08.3399 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema. |
| LCD 33822 | Noridian Local Coverage Determination for Glucose Monitors (Glucose Monitors). |
| Policy Article A52464 | Noridian Glucose Monitor - Policy Article A52464. |
Prior Authorization, Documentation, and Billing Actions
Prior authorization required with clinical documentation
Prior authorization is required for CGM devices and must include clinical documentation submitted with the PA request, including physician progress notes, device-specific training documentation, laboratory reports (HbA1c), and blood glucose logs as available. Covered CPT/HCPCS and procedure codes are listed in the policy and should be included with the request where applicable.
- Include covered CPT/HCPCS or procedure codes when applicable (see policy code lists).
- Submit clinical documentation demonstrating the indication (short-term diagnostic or long-term therapeutic criteria).
Follow applicable Medicare NCDs/LCDs (e.g., Noridian LCD 33822)
When Medicare NCDs/LCDs apply, providers must follow those determinations for prior authorization and coverage — for example, Noridian LCD 33822 and related Noridian policy articles referenced in the document. The plan may require adherence to those coverage rules when applicable.
- Noridian LCD 33822 (Glucose Monitors) and Noridian policy article A52464 are cited as applicable Medicare references.
- Medicare jurisdictions referenced in the policy include Jurisdictions 5 and 8.
No step therapy sequencing specified
No explicit step therapy sequence is specified in this policy; coverage decisions are based on whether the member meets the short-term diagnostic or long-term therapeutic clinical criteria described in the policy.
- Short-term (diagnostic) use is defined for 72 hours to one week when specified indications are met.
- Long-term (therapeutic) coverage requires meeting one of the long-term clinical criteria (e.g., Type 1 diabetes or Type 2 with qualifying features).
Complete PA submission required (provider action placeholder)
Ensure complete prior authorization submission — include all required clinical documentation listed in the policy to avoid delays or denials.
- Provide the specific clinical indication that meets short-term or long-term criteria.
- Attach relevant CPT/HCPCS/procedure codes and any device-specific justification (including implantable CGM criteria if applicable).
Information required with PA request
Submit the following information with the prior authorization request when available: physician progress notes for the past six months; documentation of completion of a comprehensive diabetic program and sufficient device-specific training; laboratory reports including HbA1c; and blood glucose logs.
- Physician progress notes covering the prior six months
- Documentation of completion of a comprehensive diabetic education program and device training
- Laboratory reports including HgA1c
- Blood glucose logs
Use Appendix 2 ICD-10 diagnosis codes on submissions
When submitting CGM-related claims or prior authorization requests, include one of the applicable ICD-10 diagnosis codes listed in Appendix 2 of the policy.
- Use an appropriate code from the Appendix 2 E08–E13 or O24 series as documented in the policy.
Incomplete PA documentation may trigger denial
Failure to submit the required prior authorization documentation (physician progress notes for the past six months; documentation of device training/completion of diabetic program; laboratory reports including HbA1c; and blood glucose logs) may result in denial of the request.
- Missing physician progress notes, training documentation, HbA1c, or glucose logs are specifically cited as grounds that may trigger denial.
Noncompliance with NCD/LCD requirements may cause denials
Claims and prior authorization requests may be subject to applicable Medicare NCDs/LCDs; noncompliance with those determinations (for example Noridian LCD 33822) can lead to denial when those policies govern coverage.
- Where NCDs/LCDs apply, coverage is governed by those Medicare determinations and may limit plan coverage to the specifics of those policies.
Background and Scope
Continuous glucose monitoring (CGM) systems provide real-time or intermittently scanned measurements of interstitial glucose to support diabetes management. CGM supports identification of glucose trends, detection of hypoglycemia and hyperglycemia, and informs therapeutic decisions. CGM is an established component of management for Type 1 diabetes and is increasingly used in Type 2 diabetes, particularly for members on insulin or at risk for problematic hypoglycemia. CGM may be used short-term for diagnostic evaluation (device use 72 hours to one week) or long-term for ongoing therapeutic management when medical necessity criteria are met.
Definitions
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