CurrentUnitedHealthcarePolicy N/A

Therapeutic Continuous Glucose Monitors (CGMs) Coverage Criteria

Criteria and documentation requirements for initial and continued coverage of therapeutic CGMs (Dexcom G6/G7, FreeStyle Libre systems) for UnitedHealthcare beneficiaries; applies to prescribers requesting prior authorization for devices and supplies.

Policy Summary

PayerUnitedHealthcare

PolicyTherapeutic Continuous Glucose Monitors (CGMs) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including device selection, device-specific age criteria, confirmation of insulin-dependent diabetes, and required documentation of face-to-face encounter and evidence of device use/benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Max 1Transmitters allowed (Dexcom G6)

Max 3Dexcom sensors quantity limit

180 daysInitial authorization length

12 moReauthorization interval

2+/4+/18+Device minimum ages

Policy Summary

PayerUnitedHealthcare

PolicyTherapeutic Continuous Glucose Monitors (CGMs) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

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Coverage Criteria for Therapeutic CGMs

Initial Therapy

Covered when ALL of the following are met for initial therapy (max 6 months authorization):

Initial criteria: 1) Beneficiary has a diagnosis of insulin-dependent diabetes.

Initial criteria: 2) Beneficiary and/or caregiver is willing and able to use the therapeutic continuous glucose monitoring (CGM) system as prescribed.

Initial criteria: 3) Face-to-face encounter with the treating practitioner within six months prior to the request documenting criteria 1 and 2.within 6 months

Initial criteria: 4) Device-specific minimum age is met (Dexcom G6/G7: age ≥ 2 years; FreeStyle Libre 2 and Libre 3: age ≥ 4 years; FreeStyle Libre 14 day: age ≥ 18 years).

Initial criteria: 5) For Dexcom G6 or G7, documentation whether the beneficiary has a smart device to receive transmissions or requires a Dexcom receiver.

Initial criteria: 6) Device selection and requested quantities are within the form limits (e.g., Dexcom G6 transmitter max 1; Dexcom sensors max 3; reader/sensor quantities per form).

See form for device-specific maximum quantities and allowable length of therapy (initial authorization up to 180 days).

Initial criteria: 7) For FreeStyle Libre 14 day, either prior trial of Dexcom G6/G7 or FreeStyle Libre 2 or 3 is documented, or a clinical reason is provided why those devices cannot be used.

First Reauthorization

Covered on first reauthorization when ALL of the following are met (max 12-month authorization):

First reauth: 10) Beneficiary has been using the CGM as prescribed.

First reauth: 11) Beneficiary has been able to improve glycemic control while using the CGM.

First reauth: 12) Documentation whether the beneficiary continues to use an external insulin pump (if applicable).

Authorization for first reauthorization up to 12 months.

Subsequent Reauthorizations

Covered on subsequent reauthorizations when ALL of the following are met (max 12-month authorization):

Subsequent reauth: 13) Face-to-face encounter with the ordering practitioner to evaluate CGM efficacy within 3 months prior to submission of the reauthorization request.within 3 months

Subsequent reauth: 14) Beneficiary has been using the CGM system as prescribed.

Subsequent reauth: 15) Beneficiary has been able to maintain or further improve glycemic control.

Subsequent reauth: 16) Beneficiary continues to use an external insulin pump (if applicable).

Authorization for subsequent reauthorizations up to 12 months.

The prior authorization form explicitly asks whether the beneficiary has a diagnosis of gestational diabetes (initial therapy question 5). Presence of gestational diabetes is captured as part of the clinical assessment and may affect coverage determinations; include the beneficiary's pregnancy-related diagnosis when completing the request so the reviewer can consider whether standard therapeutic CGM criteria for insulin‑dependent diabetes apply or whether additional evaluation is needed.

Requests that do not include required documentation identified on the form may be considered incomplete or not medically necessary. Required elements include a documented face‑to‑face encounter within six months for initial requests (and within three months of submission for subsequent reauthorizations), evidence the beneficiary is willing and able to use the CGM, and for reauthorization requests documentation that the beneficiary has been using the CGM as prescribed with improved or maintained glycemic control. Missing any of these items can result in denial or delay of coverage.

Prior Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for therapeutic continuous glucose monitoring (CGM) devices. Submit a completed prior authorization form that includes beneficiary and prescriber information, selected device and quantities, length of therapy requested, and the prescriber signature. Initial authorizations are limited to a maximum of 180 days; first and subsequent reauthorizations may be granted for up to 12 months when documentation supports ongoing medical need.

Submit beneficiary demographics, beneficiary ID, and date of birth
Include prescribing provider name and NPI, requester contact and phone
Specify device model (e.g., Dexcom G6, Dexcom G7, FreeStyle Libre 14 day/2/3), transmitter/sensor/reader quantities, and requested length of therapy
Attach documentation of a face-to-face encounter with the treating practitioner within required timeframe (initial: within 6 months; first reauth: within 3 months prior to reauthorization request for efficacy evaluation)
Prescriber signature is mandatory

Denial Risk

Triggers for Denial

Denial may occur when required documentation or clinical conditions are not met. Examples include missing or incomplete prior authorization forms, absence of a documented face-to-face encounter within the required timeframe, lack of prescriber signature, inability or unwillingness of the beneficiary/caregiver to use the device as prescribed, or failure to document insulin dependence when required.

Missing prescriber signature or incomplete beneficiary/prescriber information
No documentation of required face-to-face evaluation within the specified timeframe
Documentation that beneficiary is unable or unwilling to use the CGM as prescribed
Failure to document insulin-dependent diabetes when indicated
Insufficient clinical justification for selecting a specific device when alternatives exist

Step Therapy

Device Trial / Step Considerations

When an alternate device has not been tried, provide clinical rationale. For coverage of specific devices, ensure age-based device criteria are documented. For initial therapy, answer screening questions regarding insulin dependence, willingness/ability to use the CGM, face-to-face evaluation, pump use, gestational diabetes, and device-specific age thresholds. If the beneficiary has not trialed an alternative (e.g., Dexcom G6/G7 vs FreeStyle Libre variants), document the clinical reason why those devices are unsuitable.

Document whether beneficiary tried alternate devices; if not, provide clinical reason why alternatives could not be used
Dexcom G6/G7: beneficiary age ≥ 2 years for coverage
FreeStyle Libre 14 day: beneficiary age ≥ 18 years for coverage
FreeStyle Libre 2 and Libre 3: beneficiary age ≥ 4 years for coverage
Include answers to initial therapy questions 1–9 on the PA form; for reauthorization, document continued use and efficacy per questions 10–16

Definitions

Insulin-dependent diabetes

Insulin-dependent diabetes requirementBeneficiary must have a diagnosis of insulin-dependent diabetes to qualify for therapeutic CGM coverage.

Documentation locationQuestion 1 on the initial therapy section asks whether the beneficiary has a diagnosis of insulin-dependent diabetes; a ‘Yes’ response is required.

Scope of requirementThis diagnosis requirement applies to initial authorization and is referenced in reauthorization documentation expectations.

Smart device / Receiver

Smart device availability (Dexcom G6/G7)Beneficiary must have a smartphone/computer/tablet to receive transmissions from the Dexcom G6 or G7; if not available, the beneficiary requires a Dexcom Receiver.

Form questionQuestion 14 (Dexcom G6 and G7 only) asks whether the beneficiary has a smart device; answering ‘No’ indicates the beneficiary needs the Dexcom Receiver.

Device-specific implicationSmart device availability only applies to Dexcom G6/G7 per the form; Libre systems use a reader/reader quantity fields instead.

OpenPayer

Therapeutic Continuous Glucose Monitors (CGMs) Coverage Criteria

Coverage Criteria for Therapeutic CGMs

Device Age Requirements and Coding Details

Prior Authorization and Provider Requirements

Background

Definitions