Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyPacificSource CGM Coverage Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentPacificSourcePolicy N/A

    Diabetic Supplies

    Customize your policy alerts

    Sign up for all pacificsource policy alerts

    Know when pacificsource releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Coverage criteria, prior authorization, benefit routing, and coding for diabetic supplies, blood glucose monitors, continuous glucose monitors, implantable continuous glucose monitors, insulin, syringes, and related equipment for PacificSource members in Idaho, Montana, Oregon, and Washington.

    Policy Summary
    PayerPacificSource
    PolicyDiabetic Supplies
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateApril 29, 2012
    Next Review DateApril 1, 2023
    Key ActionObtain prior authorization for continuous glucose monitors and related accessories and supplies.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3–7 daysCGM sensor replacement
    3

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Minimum daily insulin administrations
    4/dayType II CGM testing minimum
    30030-day supply maximum
    90090-day supply maximum

    Coverage Criteria

    Commercial blood glucose monitors

    Covered when ALL of the following are met:

    Standard blood glucose monitor

    • Diagnosis: The patient has a diagnosis of Diabetes Mellitus Type I or II.
    • Training capability: The patient's physician documents that the patient is capable of being trained to use the particular device prescribed in an appropriate manner, or that a responsible individual can be trained to use the equipment and monitor the patient to assure that the intended effect is achieved.
    • Personal use: The device is designed for personal use.

    Visual impairment monitoring system

    Covered when ALL standard monitor criteria and the additional criterion are met:

    Special blood glucose monitoring system for visual impairment

    • Standard monitor criteria: The member and device meet all three conditions for coverage of a standard blood glucose monitor: Diabetes Mellitus Type I or II, documented capability for the patient or a responsible individual to be trained to use and monitor the equipment, and a device designed for personal use.
    • Visual impairment certification: The member's physician certifies that the visual impairment is severe enough to require use of the special monitoring system.

    Commercial continuous glucose monitors

    Covered when ANY of the following pathways is met:

    CGM eligibility pathways

    • Type I pathway

      • The member has a diagnosis of Type I Diabetes Mellitus.

    • Type II pathway

      • The member has a diagnosis of Type II Diabetes Mellitus.
      • The member is currently on insulin treatment of at least three subcutaneous injections daily or on an insulin pump.
      • The member performs at least four blood glucose tests per day with a blood glucose monitoring device.>= 4 tests per day

    Implantable CGM initial procedure

    Covered when ALL of the following are met:

    Initial I-CGM implantation and removal

    • The member is 18 years of age or older.Age 18 or older
    • The member has a diagnosis of Diabetes Mellitus Type I or Type II.
    • The member is insulin-treated with at least three daily administrations of insulin or uses an insulin infusion pump.At least 3 daily insulin administrations or insulin infusion pump

    Implantable CGM replacement

    Covered when ALL of the following are met:

    I-CGM replacement

    • Initial eligibility: The initial I-CGM criteria are met: the member is 18 years of age or older, has Type I or Type II diabetes, and is insulin-treated with at least three daily administrations of insulin or uses an insulin infusion pump.

    • Replacement event

      • The member's sensor has failed.
      • The device lifespan has expired.

    Insulin, syringes, and other diabetic supplies

    Coverage depends on the applicable benefit and member plan:

    Benefit coverage for diabetic supplies

    • Insulin and syringes: Diabetic insulin and syringes are covered under the prescription drug endorsement only. If the group does not have a prescription drug endorsement, the member has no coverage for insulin and syringes.
    • Other diabetic supplies: Lancets, test strips, glucostix, and needle-free injection devices may be covered under either the medical plan's durable medical equipment benefit or the prescription drug benefit.
    • Benefit selection and limitations: Members may choose to purchase eligible diabetic supplies using the pharmacy or DME benefit. Pharmacy coverage follows the PacificSource Diabetic Supply formulary. DME reimbursement is based on the provider's participating or non-participating status and the contracted or allowed amount.

    Medicaid and Medicare coverage standards

    Coverage follows the applicable program-specific external criteria:

    Program-specific coverage standards

    • Medicaid: PacificSource Community Solutions follows Guideline Note 108 of the OHP Prioritized List of Health Services for coverage of continuous blood glucose monitors, and OAR 410-122-0520 plus Guideline Note A2 for self-monitoring of blood glucose in diabetes.
    • Medicare: PacificSource Medicare follows CMS National Coverage Determination 40.2 for blood glucose monitors, continuous blood glucose monitors, implantable continuous glucose monitors, and accessories and supplies, including the identified glucose monitor LCDs L33822 and L38657.

    Insulin and syringes are excluded from the medical benefit and are covered only under the prescription drug endorsement. Reimbursement receipts for these items process under the pharmacy benefit. If the member’s group does not include a prescription drug endorsement, insulin and syringes are not covered.

    Medical Necessity Determinations

    Blood glucose monitor

    Covered when ALL of the following are met:

    • The patient has a diagnosis of Diabetes Mellitus Type I or II.
    • The patient's physician documents that the patient is capable of being trained to use the particular device prescribed in an appropriate manner, or that a responsible individual can be trained to use the equipment and monitor the patient to assure that the intended effect is achieved.
    • The device is designed for personal use.

    Continuous glucose monitor

    Covered when ANY medical necessity pathway is met:

    CGM eligibility pathways

    • Type I pathway

    Coding and Quantity Limits

    Coding Informationmixed
    95249Professional fee for patient-supplied equipment
    95250Professional fee for provider- supplied equipment
    95251Professional fee for device interrogation/interpretation
    Modifier 25For two of the above codes (95249, 95250, 95251) on the same date of service
    0446TCreation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training
    0447TRemoval of implantable interstitial glucose sensor from subcutaneous pocket via incision
    0448TRemoval of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor
    A9276Sensor: invasive (e.g., subcutaneous), disposable for use with interstitial continuous glucose monitoring system, 1 unit
    A9277Transmitter: external, for use with interstitial continuous glucose monitoring system
    A9278Receiver (monitor): external, for use with interstitial continuous glucose monitoring system
    1–10 of 13
    1/2
    Coding Informationmixed
    95249Professional fee for patient-supplied equipment
    95250Professional fee for provider- supplied equipment
    95251Professional fee for device interrogation/interpretation
    Modifier 25For two of the above codes (95249, 95250, 95251) on the same date of service
    0446TCreation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training
    0447TRemoval of implantable interstitial glucose sensor from subcutaneous pocket via incision
    0448TRemoval of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor
    A9276Sensor: invasive (e.g., subcutaneous), disposable for use with interstitial continuous glucose monitoring system, 1 unit
    A9277Transmitter: external, for use with interstitial continuous glucose monitoring system
    A9278Receiver (monitor): external, for use with interstitial continuous glucose monitoring system
    1–10 of 13
    1/2
    30-Day Test Strip or Lancet Supply
    Supply period30-day DME supply
    Maximum quantity300 test strips or lancets, or 3 boxes of 100 count
    Pre-authorizationOrders exceeding the maximum require pre-authorization by Health Services
    90-Day Test Strip or Lancet Supply
    Supply period90-day DME supply
    Maximum quantity900 test strips or lancets, or 9 boxes of 100 count
    Pre-authorization

    Authorization and Provider Actions

    Prior Authorization

    CGM Prior Authorization Required

    Prior authorization is required for continuous glucose monitors (CGMs) and related accessories and supplies. Coverage may be medically necessary for members with Type I diabetes, or for members with Type II diabetes who meet both insulin-treatment or pump-use and blood-glucose-testing requirements.

    • Type I diabetes mellitus.
    • Type II diabetes mellitus with at least three daily subcutaneous insulin injections or an insulin pump, and at least four blood glucose tests per day.
    Prior Authorization

    I-CGM Prior Authorization Required

    Prior authorization is required for implantation and removal of an implantable continuous glucose monitor (I-CGM), subject to age, diagnosis, and insulin-treatment requirements.

    • Member is age 18 or older.
    • Diagnosis of Type I or Type II diabetes mellitus.
    • At least three daily insulin administrations or use of an insulin infusion pump.

    Background

    A blood glucose monitor measures glucose from a blood sample applied to a reagent strip. Lancets obtain the blood sample, while test strips, glucostix, and other necessary supplies support device operation. Continuous glucose monitors measure interstitial glucose continuously or at regular intervals with a subcutaneous sensor; implantable monitors use a subcutaneously implanted sensor for longer-term monitoring. Appropriate use depends on the member’s ability—or a responsible individual’s ability—to follow the device procedures.

    Glucose Monitoring Definitions

    Non-Therapeutic Continuous Glucose Monitor
    DefinitionA continuous glucose monitor that requires the user to verify glucose levels or trends displayed on the CGM with a blood glucose monitor
    Confirmatory methodVerification is performed with a blood glucose monitor (BGM)
    TimingVerification is required before making treatment decisions
    Therapeutic Continuous Glucose Monitor
    DefinitionA continuous glucose monitor used to make treatment decisions
    Confirmation requirementA stand-alone blood glucose monitor is not needed to confirm testing results

    Replacement Intervals

    Continuous Glucose Monitor Sensor
    EquipmentContinuous glucose monitor sensor
    Replacement intervalEvery 3 to 7 days
    VariationThe interval depends on the CGM model
    Implantable Continuous Glucose Monitor Sensor
    EquipmentImplantable continuous glucose monitor sensor
    Intended useLong-term use
    Sensor lifespan90 to 180 days

    Required Documentation

    Documentation Required

    Document monitor medical necessity

    Document medical necessity and appropriate-use capability for the prescribed blood glucose monitoring equipment. Physician documentation or certification is required for standard monitor eligibility, training capability, and severe visual impairment.

    Documentation Required

    Submit I-CGM clinical documentation

    Submit clinical documentation supporting I-CGM implantation, removal, or replacement, including age, diabetes diagnosis, insulin treatment or pump use, and, for replacement, sensor failure or an expired device lifespan.

    Prior Authorization

    Pre-authorize excess test strip or lancet quantities

    Obtain Health Services pre-authorization for test strip or lancet orders above the DME quantity maximum.

    Policy Summary
    PayerPacificSource
    PolicyDiabetic Supplies
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateApril 29, 2012
    Next Review DateApril 1, 2023
    Key ActionObtain prior authorization for continuous glucose monitors and related accessories and supplies.
    SourceLink
    On This Page
    Coverage CriteriaMedical Necessity DeterminationsCoding and Quantity LimitsAuthorization and Provider ActionsBackgroundGlucose Monitoring DefinitionsReplacement IntervalsRequired Documentation
    • The member has a diagnosis of Type I Diabetes Mellitus.

  1. Type II pathway

    • The member has a diagnosis of Type II Diabetes Mellitus.
    • The member is currently on insulin treatment of at least three subcutaneous injections daily or on an insulin pump.
    • The member performs at least four blood glucose tests per day with a blood glucose monitoring device.>= 4 tests per day

    2. Implantable continuous glucose monitor

    Covered when ALL of the following are met:

    • The member is 18 years of age or older.Age 18 or older
    • The member has a diagnosis of Diabetes Mellitus Type I or Type II.
    • The member is insulin-treated with at least three daily administrations of insulin or uses an insulin infusion pump.At least 3 daily insulin administrations or insulin infusion pump
    Orders exceeding the maximum require pre-authorization by Health Services
    Type II CGM Blood Glucose Testing
    Applicable pathwayType II diabetes continuous glucose monitor coverage
    Testing frequencyAt least 4 blood glucose tests per day
    Testing methodTesting must be performed with a blood glucose monitoring device
    Insulin Treatment for CGM or I-CGM
    Treatment requirementInsulin treatment is required for applicable CGM or I-CGM coverage
    Injection frequencyAt least 3 daily subcutaneous insulin injections
    AlternativeUse of an insulin pump or insulin infusion pump satisfies the alternative treatment pathway
    I-CGM Implantation
    Minimum age18 years of age or older
    DiagnosisType I or Type II diabetes
    Additional requirementInsulin treatment with at least 3 daily administrations or use of an insulin infusion pump
    Documentation Required

    Document Monitor Training Capability

    Document that the member can be trained to use the prescribed blood glucose monitor appropriately, or that a responsible individual can be trained to use the equipment and monitor the member to ensure the intended effect is achieved.

    • The device must be designed for personal use.
    Documentation Required

    Certify Qualifying Visual Impairment

    For a special blood glucose monitoring system for a member with visual impairment, obtain physician certification that the impairment is severe enough to require the special monitoring system.

    • The member and device must also meet all standard blood glucose monitor coverage conditions.
    Documentation Required

    Document I-CGM Clinical Eligibility

    For I-CGM implantation or removal, document the member's age, diabetes diagnosis, and insulin treatment or pump use to establish medical-necessity eligibility.

    • Age 18 or older.
    • Type I or Type II diabetes mellitus.
    • At least three daily insulin administrations or use of an insulin infusion pump.
    Documentation Required

    Document I-CGM Replacement Eligibility

    For I-CGM replacement, document that the member continues to meet the initial I-CGM eligibility criteria and that the sensor has failed or the device lifespan has expired.

    • Replacement requires continuing satisfaction of the section A criteria.
    • Document sensor failure or expiration of the device lifespan.
    Denial Risk

    Standard Monitor Criteria Not Met

    Standard blood glucose monitor coverage is not supported when the member does not have Type I or Type II diabetes, cannot be trained to use the prescribed device and has no responsible individual who can assist, or the device is not designed for personal use.

    • Confirm the diabetes diagnosis, training capability or responsible-person support, and personal-use design before submitting.
    Denial Risk

    Visual Impairment Criteria Not Met

    A special monitoring system for visual impairment is not supported when standard monitor coverage criteria are not met or the physician has not certified that the visual impairment is severe enough to require the special system.

    • Obtain the required physician certification and verify all standard monitor criteria.
    Denial Risk

    CGM Medical Necessity Criteria Not Met

    CGM coverage may be denied when the member does not meet either the Type I pathway or the complete Type II pathway.

    • Type I pathway: diagnosis of Type I diabetes mellitus.
    • Type II pathway: at least three daily subcutaneous insulin injections or an insulin pump, and at least four blood glucose tests per day.
    Denial Risk

    I-CGM Eligibility Criteria Not Met

    I-CGM implantation, removal, or replacement may be denied when the member is under age 18, lacks a Type I or Type II diabetes diagnosis, or does not receive at least three daily insulin administrations and does not use an insulin infusion pump.

    • For replacement, also document sensor failure or expiration of the device lifespan.
    • Replacement requires continued eligibility under the initial I-CGM criteria.
    Prior Authorization

    Excess Diabetic Supply Quantity

    When diabetic test strips or lancets are obtained through the DME benefit, quantities above the standard limit require Health Services pre-authorization.

    • Maximum without pre-authorization: 300 strips or lancets, or 3 boxes of 100, per 30 days.
    • Maximum without pre-authorization: 900 strips or lancets, or 9 boxes of 100, per 90 days.
    • Orders exceeding these limits may be filled within 10 days of exhaustion of the supply.
    Clinical use
    CGM results may be used directly for treatment decisions
    Implantable Continuous Glucose Monitor
    SensorImplantable fluorescence-based sensor
    Transmission and displaySmart transmitter and mobile application
    Information displayedGlucose values, trends, and alerts on the patient's compatible mobile device
    Non-Therapeutic Continuous Glucose Monitor
    DefinitionA continuous glucose monitor requiring verification of displayed glucose levels or trends
    Confirmatory monitoringThe user must verify CGM information with a blood glucose monitor
    Treatment decisionsVerification is required before making treatment decisions
    Therapeutic Continuous Glucose Monitor
    DefinitionA continuous glucose monitor used to make treatment decisions
    Stand-alone confirmationTreatment decisions do not require confirmation with a stand-alone blood glucose monitor
    Testing resultsCGM testing results may be used without stand-alone BGM confirmation
    Implantable Continuous Glucose Monitor
    SensorImplantable fluorescence-based sensor
    Transmitter and applicationSmart transmitter and mobile application
    Displayed informationGlucose values, trends, and alerts are displayed on the patient's compatible mobile device
    Implantable Continuous Glucose Monitor Replacement
    EquipmentImplantable continuous glucose monitor
    Replacement triggerThe sensor fails or the device lifespan has expired
    Coverage conditionThe initial I-CGM criteria must continue to be met
    • 30-day supply: maximum 300 or 3 boxes/100 count
    • 90-day supply: maximum 900 or 9 boxes/100 count