Continuous Glucose Monitors (Freestyle Libre & Dexcom) — Prior Authorization Criteria
Customize your policy alerts
Sign up for all West Virginia Bureau for Medical Services (Department of Human Services) policy alerts
Know when West Virginia Bureau for Medical Services (Department of Human Services) releases new policies or updates existing guidance.
Monitor payer policy activity
Prior authorization criteria for coverage of specified continuous glucose monitors (CGMs) under West Virginia Medicaid, detailing initial approval, reauthorization, and special pediatric provisions. Applies to providers requesting CGM coverage for WV Medicaid members.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial Authorization
Covered when ALL of the following are met:
Pediatric patients (<18 years) with Type 1 Diabetes receive prior authorization with no further restrictions beyond the manufacturer's label.
Reauthorization / Continuation
Reauthorization granted when ALL of the following are met:
Continuation of therapy will be granted for 6 months upon meeting these criteria.
None are explicitly listed beyond failure to meet the stated eligibility requirements. Coverage is contingent on meeting the core criteria: diagnosis of Type 1, Type 2, or Gestational Diabetes; meeting the manufacturer's age restrictions; and being on an intensive insulin regimen (multiple daily injections — at least 3 injections per day — or insulin pump therapy). Requests that do not meet these requirements may be denied.
Use of a continuous glucose monitor (CGM) will be considered not medically necessary when the member does not meet the policy’s eligibility requirements. Specifically, coverage is not supported if the patient lacks a qualifying diagnosis (Type 1, Type 2, or Gestational Diabetes), is outside the device manufacturer’s labeled age range, or is not on an intensive insulin regimen (defined as multiple daily injections of insulin — at least 3 injections per day — or insulin pump therapy). For reauthorization, failure to provide objective evidence of ongoing CGM use (pharmacy claims for the prior approval period and documentation showing CGM use at least twice daily for a minimum of 24 days in the past 30 days) may also result in noncoverage.
Products and Documentation Metrics
| Freestyle Libre | Continuous Glucose Monitor product covered (per document title) |
| Dexcom | Continuous Glucose Monitor product covered (per document title) |
Prior Authorization, Documentation, and Provider Responsibilities
Prior authorization required; initial approval = 3 months
Prior authorization is required for covered CGMs. Initial approvals are issued for 3 months.
Step therapy not specified
No step-therapy sequencing is specified in this policy; coverage decisions are based on diagnosis, manufacturer's age limits, and insulin regimen requirements instead of prior medication trials.
Reauthorization: submit pharmacy claims and objective CGM use data
For reauthorization submit pharmacy claims for the prior approval period plus objective evidence of CGM use showing daily use over the past 30 days.
- Pharmacy claims data for the prior approval duration
- Objective CGM documentation such as log data, trend graphs, and/or office visit notes showing use at least twice daily for a minimum of 24 days in the past 30 days
Recommend diabetes educator instruction when CGM prescribed
The WV Medicaid DUR Board strongly recommends that a diabetic educator provide instruction and assistance whenever a continuous glucose monitor is prescribed.
- Provide diabetes education and device training at initiation to support correct CGM use and adherence
Denial risk if diagnosis, age, or insulin regimen criteria are not met
Requests may be denied if the patient does not meet the policy's basic eligibility criteria for diagnosis, age, or intensive insulin regimen.
- Diagnosis must be Type 1, Type 2, or Gestational Diabetes
- Patient must meet all age restrictions in the manufacturer's label
- Regimen must include multiple daily injections (at least 3 injections per day) or current insulin pump therapy
Key Definitions
Background
Continuous glucose monitors provide near-real-time glucose readings and trend information to support glycemic management. WV Medicaid requires prior authorization for covered CGM products and applies criteria intended to ensure appropriate use: the member must have a qualifying diabetes diagnosis, meet the device manufacturer’s age restrictions, and be on an intensive insulin regimen (multiple daily injections — at least 3 injections per day — or insulin pump therapy). Pediatric members under 18 with Type 1 Diabetes are eligible for prior authorization without additional restrictions beyond the manufacturer label. For continued coverage, objective evidence of sustained CGM use is required, including pharmacy claims for the prior approval period and documentation (log data, trend graphs, or office notes) showing CGM use at least twice daily for a minimum of 24 days in the past 30 days.
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.