DexCom Continuous Glucose Monitoring (CGM) products — Coverage and Billing
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Defines coverage and billing rules for DexCom CGM products for Pennsylvania Medicaid Fee-for-Service beneficiaries, including benefit routing (DME vs pharmacy), prior authorization, and quantity limits.
DexCom CGM products will also be covered under the pharmacy benefit for beneficiaries in the Fee-for-Service (ACCESS) delivery system effective April 1, 2020.
Prior authorization will not be required for DexCom products obtained through DME or pharmacy benefits unless quantity limits are exceeded.
Coverage and Billing Criteria
General coverage and billing
Covered when obtained through DME or pharmacy benefit with stated quantity limits
Claims for Fee-for-Service beneficiaries obtained via the pharmacy benefit should be billed using NCPDP, 837 Professional, or internet formats.
Product-specific quantity limits
Covered amounts with explicit quantity limits
NDC 08627-0014-01
NDC 08627-0051-04
NDC 08627-0090-11
NDC 08627-0016-01
NDC 08627-0053-03
NDC 08627-0091-11
Coverage is available when DexCom Continuous Glucose Monitoring (CGM) products are obtained through the Durable Medical Equipment (DME) benefit or, effective April 1, 2020, through the pharmacy benefit for Fee‑for‑Service (ACCESS) beneficiaries. Claims for pharmacy-obtained DexCom CGM products for Fee‑for‑Service beneficiaries should be billed as pharmacy claims using standard NCPDP, 837 Professional, or internet formats.
This document does not include an explicit "not medically necessary" statement. Instead, coverage is described as available through benefit routing (DME or pharmacy) with operational rules about quantity limits; prior authorization is not required unless quantity limits are exceeded.
Coding and Identifiers
| 08627-0014-01 | DexCom G5 Transmitter Kit |
| 08627-0051-04 | DexCom G5-G4 Sensor Kit |
| 08627-0090-11 | DexCom G5 Receiver Kit |
| 08627-0016-01 | DexCom G6 Transmitter |
| 08627-0053-03 | DexCom G6 Sensor |
| 08627-0091-11 | DexCom G6 Receiver |
Provider Actions, Prior Authorization, and Billing
Prior authorization not required unless quantity limits exceeded
Prior authorization is not required for DexCom products obtained through the DME or pharmacy benefits unless quantity limits are exceeded.
Confirm benefit routing and quantity adherence
When billing DexCom CGM products, follow the pharmacy or DME benefit routing described in the policy and ensure claims reflect the correct benefit and quantity limits.
Use standard pharmacy claim formats for Fee‑for‑Service pharmacy claims
For Fee‑for‑Service (ACCESS) beneficiaries, pharmacy-obtained DexCom CGM products must be billed as pharmacy claims using the standard NCPDP, 837 Professional, or internet claim formats.
Quantity limit exceedance may trigger denial or PA
Claims that exceed the stated quantity limits for transmitters, sensors, or receivers may be denied or will require prior authorization.
- G5 Transmitter Kit: 1 transmitter per 3 months (NDC 08627-0014-01)
- G6 Transmitter: 1 transmitter per 3 months (NDC 08627-0016-01)
- G5‑G4 Sensor Kit: 4 sensors per 28 days (NDC 08627-0051-04)
- G6 Sensor: 3 sensors per 30 days (NDC 08627-0053-03)
- G5 Receiver Kit: 1 receiver kit per 365 days (NDC 08627-0090-11)
- G6 Receiver: 1 receiver kit per 365 days (NDC 08627-0091-11)
Background
Continuous Glucose Monitoring (CGM) systems provide ongoing, near‑real‑time measurement of blood glucose levels throughout the day and night to support diabetes management. This policy focuses on coverage and billing rules for DexCom CGM products (benefit routing, billing formats, and quantity limits) rather than on clinical eligibility criteria.
Definitions
Medical Necessity Notes
DME medical necessity notes
Coverage tied to benefit routing and quantity limits rather than specific clinical eligibility criteria within this document.
See product-specific quantity limits for allowable supplies and replacement intervals.
Rental and Purchase Rules
| Product | NDC | Package | Purchase / Replacement Rule |
|---|---|---|---|
| {"text":"DexCom G5 Transmitter Kit","status":""},{"text":"08627-0014-01","status":""},{"text":"1 box (contains 1 transmitter)","status":""},{"text":"Purchase; 1 transmitter per 3 months","status":""} | |||
| {"text":"DexCom G5 Receiver Kit","status":""},{"text":"08627-0090-11","status":""},{"text":"1 box (contains 1 receiver)","status":""},{"text":"Purchase; 1 receiver kit per 365 days","status":""} | |||
| {"text":"DexCom G6 Transmitter","status":""},{"text":"08627-0016-01","status":""},{"text":"1 box (contains 1 transmitter)","status":""},{"text":"Purchase; 1 transmitter per 3 months","status":""} | |||
| {"text":"DexCom G6 Receiver","status":""},{"text":"08627-0091-11","status":""},{"text":"1 box (contains 1 receiver)","status":""},{"text":"Purchase; 1 receiver kit per 365 days","status":""} |
Replacement and Supply Intervals
Documentation and Claim Submission
Use standard pharmacy billing formats for pharmacy‑benefit claims
When billing DexCom CGM products through the pharmacy benefit for Fee‑for‑Service beneficiaries, use the standard pharmacy claim formats required for pharmacy submissions.
- Acceptable formats: NCPDP, 837 Professional, or internet formats.
Not Covered / Exclusions
There are no specific DME exclusions listed in this document. The only limitation noted is that claims may be denied or may require prior authorization if specified quantity limits for transmitters, sensors, or receivers are exceeded.
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