CurrentUniversity Health Alliance (HSA)Policy MPP-0083-120717
Continuous Glucose Monitoring System (CGMS) reimbursement
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Defines University Health Alliance coverage, prior authorization requirements, limitations, and payment codes for continuous and intermittent continuous glucose monitoring systems for members with diabetes.
Policy Summary
PayerUniversity Health Alliance (HSA)
PolicyContinuous Glucose Monitoring System (CGMS) reimbursement
Policy CodePolicy MPP-0083-120717
Change TypeNo material change
Effective DateAug 10, 2021
Last ReviewAug 10, 2021
Next Review Date
Key ActionSubmit prior authorization with signed physician order and documentation of diabetes type and prior 'best practices' use for initial CGMS requests.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
3 monthsminimum period of 'best practices' use
72 hoursintermittent monitoring max
A9276/A9277/A9278sample sensor/transmitter/receiver codes
95250/95251referenced CPT codes
Coverage Criteria for CGMS
Primary coverage criteria for CGMS
Covered when ALL of the following are met:
ALL of the following
- Ordered and follow-up provided by an endocrinologist or a physician or licensed healthcare provider with experience and expertise in the use of a CGMS
- Patient has been utilizing best practices for at least 3 months, including: completion of a comprehensive diabetes self-management program with carbohydrate counting; compliance with intensive insulin therapy (insulin pump or ≥3 injections/day); glucose self-testing an average of ≥3 times/day; and frequent self-adjustment of insulin dose based on glucose measurement and carbohydrate count/content of meal
- It is anticipated the patient will use the CGMS consistently on a nearly daily basis
AND for type 2 diabetes
- For members with type 2 diabetes, all type 1 criteria above are met and diabetes is suboptimally controlled
- Suboptimally controlled diabetes is defined by one or more of: HbA1c > 7%; repeated and unpredictable hypoglycemia; wide preprandial glucose fluctuations; dawn phenomenon with fasting sugars frequently >200 mg/dL; severe glycemic excursions; or hypoglycemic unawareness
Clinical indications (one or more)
- Glycosylated hemoglobin (HbA1c) greater than 7 percent
- Repeated and unpredictable hypoglycemia
- Wide fluctuations in preprandial blood glucose
- Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL
- Severe glycemic excursions
- Hypoglycemic unawareness
Replacement (when applicable)
- Documentation supports device is malfunctioning, out of warranty, and cannot be repaired
- Request for replacement is initiated by the treating physician
- Patient continues intensive insulin regimen and has been compliant with and is benefiting from CGMS use
- Documentation supports use of a receiver rather than a smart device application when requesting replacement receiver
- Documentation may support benefit from newer technology or better features for a replacement when clinically justified
Intermittent monitoring (short-term) criteria
- Monitoring performed by an endocrinologist or provider with experience and expertise in intermittent monitoring of interstitial fluid glucose
- Diabetes is suboptimally controlled despite current use of best practices (see criteria above)
- Intermittent monitoring may be used prior to insulin pump initiation to determine basal insulin levels
- Intermittent monitoring is generally conducted in 72-hour periods
Continuous monitoring may be covered concurrently with initiation of an insulin pump when criteria for both CGMS and insulin pumps are met
COVERAGE CRITERIA — Concurrent coverage
Concurrent coverage:
Continuous monitoring may be covered concurrently with initiation of an insulin pump when the CGMS criteria and the insulin pump criteria are both met
Intermittent monitoring (up to 72 hours) is covered for Type 1 and Type 2 diabetes when performed by an endocrinologist or a provider with CGMS/intermittent monitoring expertise and diabetes is suboptimally controlled
Intermittent monitoring may be used prior to insulin pump initiation to determine basal insulin levels
Limitations/Exclusions
Limitations and exclusions include the following:
Intermittent monitoring is generally conducted in 72-hour periods; it may be repeated depending on the patient’s level of diabetes control
Coverage may be considered on a case-by-case basis for patients who have been utilizing best practices for less than 3 months
Replacement of a CGMS solely for the purpose of receiving a technology upgrade is not covered
Sensors are not covered when CGMS coverage criteria are not met; a sensor unit refers to a day of use and authorization is based on number of days of sensor use (one unit = one day), not the number of sensors
A replacement receiver is not covered when a patient is using a smart device application in place of a receiver
Coding and Units of Service
CPT CodesCPT
| 95250 | Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording. |
| 95251 | Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation and report. |
HCPCS CodesHCPCS
| A9276 | Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply (90 units = 90-day supply; 365 units = 1 year). |
| A9277 | Transmitter; external, for use with interstitial continuous glucose monitoring system. |
| A9278 | Receiver (monitor); external, for use with interstitial continuous glucose monitoring system. |
| K0553 | Receiver (monitor), dedicated, for use with therapeutic continuous glucose monitor system; supplies and accessories, 1 month supply = 1 Unit of Service (1 = 3 units; 1 year = 12 units). |
| K0554 | Receiver (monitor), dedicated, for use with therapeutic continuous glucose continuous monitor system; sensor; invasive, disposable, for use with artificial [pancreas?] (listed in source). |
| S1035 | Pancreas device system (listed in HCPCS table). |
| S1037 | Receiver (monitor); external, for use with artificial pancreas device system (listed in HCPCS table). |
NDC CodesNDC
| 08627-0091-11 | DEXCOM G6 RECEIVER (RETAIL). |
| 08627-0016-01 | DEXCOM G6 TRANSMITTER (RETAIL). |
| 08627-0053-03 | DEXCOM G6 SENSOR 3-PACK (RETAIL). |
| 08627-0080-11 | DEXCOM G5 MOBILE RECEIVER KIT - BLACK. |
| 08627-0080-21 | DEXCOM G5 MOBILE RECEIVER KIT - PINK. |
| 08627-0080-31 | DEXCOM G5 MOBILE RECEIVER KIT - BLUE. |
| 08627-0014-01 | DEXCOM G5 MOBILE TRANSMITTER KIT. |
| 08627-0051-04 | DEXCOM G5 MOBILE / G4 PLATINUM SENSOR, KIT 4 PACK. |
| 57599-0002-00 | FreeStyle Libre 14 day Reader. |
| 57599-0001-01 | FreeStyle Libre 14 day Sensor. |
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Sensor day-unit accounting
Sensor day-unit definitionA9276: sensor; invasive, disposable, one unit = 1 day supply (90 units = 90-day supply; 365 units = 1 year)
Authorization basisAuthorization is based on number of days of sensor use (one unit = one day)
Transmitter unit accountingA9277: transmitter; external — 1 unit (90-day = 1 unit listed as 1; annual = 4 units)
Receiver/monitor unit accountingA9278: receiver (monitor); external — 1 unit (90-day = 1; annual = 1)
Dedicated therapeutic monitor monthly supplyK0553: supplies and accessories; 1 month supply = 1 unit (3 units = 90 days; 12 units = 1 year)
Additional HCPCS listingsK0554/S1035/S1037: other receiver/sensor/pancreas device system codes and units are listed in administrative guidelines
Prior Authorization, Documentation, and Replacement
Prior Authorization
Prior authorization and required documentation for CGMS
Prior authorization is required for initial, replacement, and continuation CGMS requests. Submit a current signed physician order and documentation that the patient has type 1 or type 2 diabetes; for initial requests also include documentation that the patient has utilized best practices (including a record/log of blood glucose and insulin administration in the month preceding the request) if an insulin pump has not been previously approved. Prior auth is not required for office-based intermittent monitoring.
- Initial CGMS: current signed physician order; documentation of diabetes type; documentation of best practices (including blood glucose and insulin administration log for the prior month) if no prior UHA-approved insulin pump; justification for intermittent monitoring when used (suboptimally controlled diabetes).
- Replacement and continuation requests: see separate requirements (replacement: malfunction/out-of-warranty proof and usage summary; continuation: periodic review and demonstration of compliance/efficacy).
- Submit prior authorization via UHA's online portal; contact UHA at 808-532-4000 to establish login if needed.
Documentation Required
Replacement authorization conditions — malfunction and out-of-warranty proof required
For replacement CGMS, the request must be initiated by the treating physician and include a current signed physician order, documentation that the CGMS is malfunctioning and out of warranty, and a summary of device use over the last month (or other documentation supporting compliance if a download is not available).
- Replacement documentation: current signed physician order; evidence the device is malfunctioning and out of warranty; one-month device use summary downloaded from the device, or documentation supporting compliance if a summary cannot be downloaded.
Key Definitions
Intermittent monitoring (short-term / up to 72 hours)
DefinitionIntermittent monitoring: short-term/professional use CGMS that stores glucose measurements for later review (typically up to 72 hours)
Typical durationIntermittent monitoring is generally conducted in 72-hour periods
PurposeUsed to detect nocturnal hypoglycemia, dawn phenomenon, postprandial hyperglycemia, and to assist management when diabetes regimens change
Prior authorizationPrior authorization is not required for office-based intermittent monitoring (per administrative guidelines)
Real-time CGMS (long-term patient use, displays real-time glucose)
DefinitionReal-time CGMS: devices designed for long-term patient use that display glucose information in real-time, allowing the patient to act on the data
Intended useMost effective when used consistently every day or nearly every day for ongoing glucose trend monitoring and treatment decisions
Components and codingLong-term systems include sensors, transmitters and receivers; HCPCS codes include A9276 (sensor), A9277 (transmitter), A9278 (receiver) with unit accounting for supplies
Scope notePolicy addresses CGMS devices but not the insulin pump component of systems that include a CGMS
Policy Summary
PayerUniversity Health Alliance (HSA)
PolicyContinuous Glucose Monitoring System (CGMS) reimbursement
Policy CodePolicy MPP-0083-120717
Change TypeNo material change
Effective DateAug 10, 2021
Last ReviewAug 10, 2021
Next Review Date
Key ActionSubmit prior authorization with signed physician order and documentation of diabetes type and prior 'best practices' use for initial CGMS requests.
SourceLink
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