Continuous Glucose Monitoring (CGM)
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This policy governs prior authorization, coverage criteria, and quantity limits for continuous glucose monitoring systems for Neighborhood Health Plan of Rhode Island members across specified product lines.
No material clinical or coverage changes in this revision.
Coverage criteria and limits for Continuous Glucose Monitoring
Initial/Authorization Criteria
Covered when ANY of the following are met and prior authorization is obtained:
Initial coverage criteria
- Member is currently utilizing non-basal insulin for the treatment of diabetes.
Authorization may be granted for 12 months.
- Member has Type 1 or Type 2 Diabetes Mellitus AND is at high risk of hypoglycemia, recurring episodes of hypoglycemia, or hypoglycemia unawareness.
Authorization may be granted for 12 months.
Quantity Limits / Coverage Duration
Quantity limits and duration:
Coverage duration: 12 months.
This policy does not apply to the Extended Family Planning (EFP) product. Services and devices addressed in this document are excluded from coverage for members whose benefits are provided under EFP.
For members enrolled in Medicare dual-eligible products (INTEGRITY for Duals/FIDE and Duals CONNECT/CO-DSNP), CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and other Medicare guidelines take precedence for coverage and medical necessity determinations. If an applicable Medicare NCD/LCD/LCA exists, Neighborhood follows that guidance. If Medicare guidance is absent or incomplete, Neighborhood will: for FIDE members, defer to the Rhode Island EOHHS guidance or widely used peer-reviewed guidelines (for example, InterQual® or internal Clinical Medical Policies) as secondary coverage through the member's Medicaid benefit; and for CO-DSNP members, defer to widely used peer-reviewed guidelines (for example, InterQual® or internal Clinical Medical Policies).
Coding, duration, and code groups
| No codes listed |
Prior authorization, submission, and provider requirements
Prior Authorization Required
Prior authorization required. An authorization of up to 12 months may be granted when either: the member is currently utilizing non‑basal insulin for the treatment of diabetes, OR the member has Type 1 or Type 2 diabetes mellitus and is at high risk of hypoglycemia, has recurring episodes of hypoglycemia, or has hypoglycemia unawareness.
- Authorization duration: up to 12 months when criteria are met
- Clinical criteria: current use of non‑basal insulin OR (Type 1 or Type 2 diabetes AND high risk of hypoglycemia / recurrent hypoglycemia / hypoglycemia unawareness)
Denial Risk if Not Authorized
Action required. Lack of prior authorization will result in denial of payment for the service or product.
How to Request Authorization
How to request authorization: Access prior authorization request forms and submission instructions on Neighborhood Health Plan of Rhode Island's website. Providers should: 1) Go to www.nhpri.org; 2) Click 'Providers'; 3) Click 'Provider Resources'; 4) Click 'Forms'; 5) Select 'Click here for a list of prior authorization request forms' and choose the appropriate form (forms are listed alphabetically).
- Website: www.nhpri.org → Providers → Provider Resources → Forms → 'Click here for a list of prior authorization request forms'
- A phone messaging system is available for requests/inquiries during and outside business hours: 1-800-963-1001
- For coding guidance, reference the Authorization Quick Reference on the website
Provider Submission Guidance
Provider reminder: Use the official prior authorization request form and follow the submission channels specified by Neighborhood. Incomplete requests or use of incorrect forms may delay processing.
Background and rationale
A continuous glucose monitoring system (CGMS) is an FDA-approved device that records glucose levels continuously throughout the day and night and automatically records average glucose while the person continues daily activities. CGMS devices are intended to assist in outpatient glycemic management by providing trend information to inform treatment adjustments.
Key definitions
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