Continuous Glucose Monitoring (CGM) Devices: Prior Authorization and Reauthorization Guidelines
Customize your policy alerts
Sign up for all partners_health_management policy alerts
Know when partners_health_management releases new policies or updates existing guidance.
Monitor payer policy activity
Guidance for prior authorization and reauthorization of continuous glucose monitoring devices for patients with NC Medicaid primary coverage enrolled with Partners Health Management, including device age-based coverage and documentation requirements for initial and ongoing authorizations.
No material clinical or coverage changes in this revision.
Coverage Criteria for Continuous Glucose Monitors
COVERAGE CRITERIA
Covered when the beneficiary meets ALL elements of at least one of the following Options (A OR B OR C):
Initial Authorization Options
- Option A: Diagnosis of insulin-dependent diabetes; patient or caregiver is willing and able to use the CGM system; face-to-face evaluation within 6 months confirming criteria have been met
All required
- Option B: Diagnosis of insulin-dependent diabetes; use of an external insulin pump
All required
- Option C: Diagnosis of gestational diabetes
Single criterion
First Reauthorization
First reauthorization (valid 12 months) is covered when ALL of the following are documented:
Second element is an OR
Subsequent Reauthorization
Subsequent reauthorizations (valid 12 months) are covered when ALL of the following are documented:
Third element is an OR
This policy applies specifically to beneficiaries for whom NC Medicaid is the primary health insurance. Guidance, prior authorization requirements, and reauthorization criteria in this document are intended for that population only; other patient populations and payers are not addressed here.
Provider Authorization, Documentation, and Submission Actions
Prior authorization required; initial auth valid 6 months
Prior authorization is required for initial CGM coverage. Initial authorizations are valid for 6 months and must include documentation that the beneficiary meets one of the specified Options (A, B, or C).
- Initial authorization period: 6 months
Reauthorization criteria and durations (first and subsequent)
First reauthorization is valid for 12 months and requires documentation that the beneficiary is using the CGM as prescribed and either demonstrates improved glycemic control or continues use of an external insulin pump. Subsequent reauthorizations (12 months) require a recent face-to-face evaluation, continued appropriate use, and either maintenance/improvement of glycemic control or ongoing pump use.
- First reauthorization: beneficiary using CGM as prescribed AND (improved glycemic control OR continued external insulin pump use)
- Subsequent reauthorizations: face-to-face evaluation within past 3 months; continued appropriate use; AND (maintenance/further improvement of glycemic control OR ongoing external insulin pump use)
Documentation required for initial authorization and reauthorizations
Initial authorization must include documentation that the beneficiary meets one of Options A, B, or C. Option A requires diagnosis of insulin-dependent diabetes, patient/caregiver willingness and ability to use the CGM system, and a face-to-face evaluation within 6 months confirming criteria. Option B requires diagnosis of insulin-dependent diabetes and use of an external insulin pump. Option C requires diagnosis of gestational diabetes. Reauthorization documentation requirements mirror the reauthorization criteria.
- Option A (all required): diagnosis of insulin-dependent diabetes; patient/caregiver willing and able to use the CGM; face-to-face evaluation within 6 months confirming criteria
- Option B: diagnosis of insulin-dependent diabetes; use of an external insulin pump
- Option C: diagnosis of gestational diabetes
- Reauthorization documentation: see first and subsequent reauthorization requirements
Submission resources and contact for Tailored Plan patients
For Tailored Plan patients, providers must use the CGM prior authorization request form and prescribing resources available on the Partners Health Management Pharmacy webpage. For assistance contact the Partners Pharmacy Team at PharmacyTeam@PartnersBHM.org and encrypt any emails that contain PHI.
- Use the CGM prior authorization request form on the Partners Health Management Pharmacy webpage
- Contact PharmacyTeam@PartnersBHM.org for assistance
- Encrypt emails containing Protected Health Information (PHI)
Denial risk if initial criteria not documented
Failure to document that the beneficiary meets one of the required initial authorization Options (A, B, or C) may result in denial of the prior authorization request.
- Ensure records demonstrate one complete Option (A, B, or C) to avoid denial
Denial risk for missing reauthorization evidence
For reauthorization, lack of documentation showing the beneficiary is using the device as prescribed and either improved glycemic control (or continued external insulin pump use for first reauth) — or, for subsequent reauths, absence of a face-to-face evaluation within the past 3 months and evidence of continued benefit — may lead to denial.
- First reauthorization requires prescribed use plus (improved glycemic control OR continued external insulin pump use)
- Subsequent reauthorizations require a face-to-face evaluation within past 3 months, continued appropriate use, AND (maintenance/improvement of glycemic control OR ongoing pump use)
Definitions and Authorization Durations
Background
Continuous glucose monitoring (CGM) systems provide ongoing interstitial glucose readings to support management of insulin-dependent diabetes and gestational diabetes. The coverage and prior authorization guidance in this document follow the NC Medicaid outpatient pharmacy prior approval criteria and are intended to ensure appropriate patient selection and documented clinical benefit when CGM devices and related supplies are prescribed.
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.