Effective July 15, 2020, HCSC considers long-term continuous glucose monitoring of glucose levels in interstitial fluid medically necessary in patients with diabetes (Type 1 or Type 2 DM) who are willing and able to use the device, have adequate medical supervision, and are on multiple daily doses of insulin or an insulin pump. (Reference: Medical Policy Number DME101.005)
Effective April 1, 2020, Blue KC will also offer coverage for Continuous Glucose Monitors (CGMs) as a pharmacy benefit. While members can continue to utilize their DME benefits instead of pharmacy benefits for CGMs, some brands may eventually no longer be available through DME suppliers. Additionally, the process of obtaining a CGM through the pharmacy is likely a more timely, convenient, and overall better member experience.
Effective April 20, 2020 Aetna considers the long-term (greater than 1 week) therapeutic use of continuous glucose monitoring devices medically necessary in adults aged 18 years and older with type 1 diabetes, adults with type 2 diabetes using intensive insulin regimens (multiple (3 or more) daily injections or insulin pump therapy) who are not meeting glycemic targets, and for younger persons with type 1 diabetes.
Missouri Medicaid’s Pharmacy Program will begin covering the Dexcom G6 Continuous Glucose Monitoring (CGM) System as the preferred CGM system effective April 2, 2020.
Source: Centers for Medicare & Medicaid Services
Key Takeaway: CMS expanded Medicare coverage for therapeutic CGMs. Most notably, eliminating a requirement that beneficiaries use four fingerstick tests per day prior to accessing CGM. According to the local coverage determination, “there is no evidence to support that frequent SMBG (≥4 times per day) as a prerequisite for initiating CGM use is predictive of improved health outcomes”.
New Coverage Criteria (Effective July 18, 2021)
The revised LCD indicates that Medicare coverage for CGMs will be available if the beneficiary meets the following criteria:
Source: Diabetes Technology and Therapeutics
Key Takeaway: There is growing and compelling evidence that CGM coverage should be offered to all patients who can benefit from this technology regardless of diabetes type and history of SMBG use. The current restrictions, which are based on outdated evidence and questionable assessments, are not supported in the literature. Moreover, they ignore the burden frequent SMBG places on individuals. Given the growing prevalence of diabetes, the persistent preponderance of individuals with suboptimal glycemic control, and the exorbitant and largely preventable cost of diabetes complications, opinion-based constraints should not continue to supplant evidence-based clinical management.
*Washington, D.C.= Rx Coverage
|Rx Coverage||Pediatrics Only (published coverage policy)|
|Type 1 Type 2||No Published Coverage Policy|
*Map updated January 12, 2021