Description

Continuous glucose monitoring systems (CGMS) are devices that automatically measure glucose levels throughout the day. These readings help detect any patterns or trends with an individual’s glucose levels and are intended to assist in calculating the insulin dosage needed to manage glycemic control. CGMS use sensors that are inserted under the skin which measure and record the glucose level and then convert these measurements into equivalent blood glucose readings.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.

A continuous glucose monitor (CGM) may be considered medically necessary when ONE of the following criteria are met:

• Individual has type 1 diabetes and is receiving short- or rapid-acting insulin therapy; or
• Individual has type 2 diabetes and is receiving short- or rapid- acting insulin therapy; or
• Individual has gestational diabetes or is pregnant and a CGM is recommended by the provider; or
• Individual has an insulin pump

All other uses are considered experimental/investigational and therefore, non-covered because their safety and/or effectiveness cannot be established by the review of the published peer-reviewed literature.

Procedure Codes

Non-invasive CGM

Non-invasive CGM and related supplies are considered experimental/investigational, and therefore, non-covered. Despite the fact that these devices have received FDA approval, there is a lack of long-term studies demonstrating that the use of these devices is associated with an improvement in final health outcomes, i.e., improved diabetic control based either on decreasing hemoglobin A1c values and/or decreasing incidence of hypoglycemia.

Procedure Codes

Remote CGM

A remote interstitial CGM (e.g., mySentry™) is considered investigational and therefore, non-covered. Remote interstitial CGM does not provide new or additional clinical information or data that is substantially different from the base CGM.

Procedure Codes

Note:  Eversense® CGM system is considered investigational and therefore, non-covered. The safety of the device cannot be established by published peer-reviewed literature.

Note: Upgrade to or replacement of an existing CGM is considered not medically necessary when requested for convenience or simply to upgrade to a newer technology, when the current components remain functional, or when the current components remain under warranty. Replacement is not covered due to loss, negligence or improper use.

Note: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 0446T, 0447T, 0448T, 95249, 95250, 95251, A9276, A9277, A9278, K0553, K0554, S1034, S1035, S1036 and S1037