Prior authorization with required clinical documentation

Prior authorization is required for CGM devices and related procedures. Include the following clinical documentation with the prior authorization request when available: physician progress notes for the past six months; documentation of completion of a comprehensive diabetes program and sufficient training regarding the specific device; recent laboratory reports including HbA1c; and blood glucose logs.

• Physician progress notes (past 6 months)
• Documentation of completion of a comprehensive diabetes program
• Device-specific training documentation
• Laboratory reports including HbA1c
• Blood glucose logs

Follow NCD/LCD; plan discretion for additional indications

Follow any applicable Medicare NCDs and LCDs when billing Medicare Part B; the policy identifies Noridian LCD 33822 and Policy Article A52464 as relevant. The health plan may cover additional indications at its discretion.

• Comply with applicable NCD/LCD requirements (e.g., Noridian LCD 33822)
• Health plan may cover additional indications at its discretion

Step therapy not required

No step therapy requirements are specified in this policy for CGM devices or related supplies.

Claims must include applicable diagnosis and follow CMS guidance

Providers should ensure claims include an applicable ICD‑10 diagnosis from Appendix 2 and follow CMS/NCD/LCD guidance when billing Medicare Part B.

• Document an applicable ICD‑10 diagnosis from Appendix 2 on claims
• Follow CMS/NCD/LCD guidance referenced in the policy when billing Medicare Part B

Prior authorization — required documentation checklist

Prior authorization requests must include: physician progress notes for the past six months; documentation of completion of a comprehensive diabetes program and sufficient device training; recent HbA1c laboratory reports; and blood glucose logs.

• Physician progress notes (past 6 months)
• Completion of comprehensive diabetes program
• Sufficient training regarding specific device
• Laboratory reports including HbA1c
• Blood glucose logs

Diagnosis coding and CMS guidance for claims

When submitting claims, document an applicable ICD‑10 diagnosis code from Appendix 2 and follow any applicable NCD/LCD guidance (e.g., Noridian LCD 33822) and CMS billing instructions for Medicare Part B.

• Use an Appendix 2 ICD‑10 diagnosis code on claims
• Adhere to NCD/LCD guidance and CMS billing rules for Medicare Part B

Denial risk — insufficient clinical indication or excluded device

Requests lacking documentation that the member meets one of the listed diagnostic or therapeutic criteria, or requests for excluded devices or convenience software, may be denied.

• Denial risk if documentation does not show member meets diagnostic/therapeutic criteria (e.g., hypoglycemia unawareness, wide glucose fluctuations)
• Denial risk for excluded items (e.g., GlucoWatch, software for data download, combination convenience devices)

Denial risk — Medicare/NCD/LCD noncompliance

Claims that do not comply with applicable NCD/LCD guidance or Medicare contractor requirements (for example Noridian LCD 33822 and related policy article) may be denied.

• Noncompliance with NCD/LCD (e.g., Noridian LCD 33822) or Medicare contractor rules can result in claim denials