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Continuous Glucose Monitors (CGMS)

Section: Durable Medical Equipment
Effective Date: January 01, 2020
Revised Date: December 18, 2019

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

0446T 0447T 0448T 95249 95250 95251 A9276
A9277 A9278 K0553 K0554 S1034 S1035 S1036
S1037

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

S1030  S1031

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

A9999

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

E10.10 E10.11 E10.21 E10.22 E10.29 E10.311 E10.319
E10.3211 E10.3212 E10.3213 E10.3291 E10.3292 E10.3293 E10.3311
E10.3312 E10.3313 E10.3391 E10.3392 E10.3393 E10.3411 E10.3412
E10.3413 E10.3419 E10.3491 E10.3492 E10.3493 E10.3511 E10.3512
E10.3513 E10.3521 E10.3522 E10.3523 E10.3529 E10.3531 E10.3532
E10.3533 E10.3541 E10.3542 E10.3543 E10.3551 E10.3552 E10.3553
E10.3591 E10.3592 E10.3593 E10.36 E10.37X1 E10.37X2 E10.37X3
E10.39 E10.40 E10.41 E10.42 E10.43 E10.44 E10.49
E10.51 E10.52 E10.59 E10.610 E10.618 E10.620 E10.621
E10.622 E10.628 E10.630 E10.638 E10.641 E10.649 E10.65
E10.69 E10.8 E10.9 E11.00 E11.01 E11.21 E11.22
E11.29 E11.311 E11.319 E11.3211 E11.3212 E11.3213 E11.3291
E11.3292 E11.3293 E11.3311 E11.3312 E11.3313 E11.3391 E11.3392
E11.3393 E11.3411 E11.3412 E11.3413 E11.3491 E11.3492 E11.3493
E11.3511 E11.3512 E11.3513 E11.3521 E11.3522 E11.3523 E11.3531
E11.3532 E11.3533 E11.3541 E11.3542 E11.3543 E11.3551 E11.3552
E11.3553 E11.3591 E11.3592 E11.3593 E11.36 E11.37X1 E11.37X2
E11.37X3 E11.39 E11.40 E11.41 E11.42 E11.43 E11.44
E11.49 E11.51 E11.52 E11.59 E11.610 E11.618 E11.620
E11.621 E11.622 E11.628 E11.630 E11.638 E11.641 E11.649
E11.65 E11.69 E13.00 E13.01 E13.10 E13.11 E13.21
E13.22 E13.29 E13.311 E13.319 E13.321 E13.3211 E13.3212
E13.3213 E13.329 E13.3291 E13.3292 E13.3293 E13.331 E13.3311
E13.3312 E13.3313 E13.339 E13.3391 E13.3392 E13.3393 E13.341
E13.3411 E13.3412 E13.3413 E13.349 E13.3491 E13.9492 E13.3493
E13.351 E13.3511 E13.3512 E13.3513 E13.359 E13.3591 E13.3592
E13.3593 E13.36 E13.39 E13.40 E13.41 E13.42 E13.43
E13.44 E13.49 E13.51 E13.52 E13.59 E13.610 E13.618
E13.620 E13.621 E13.622 E13.628 E13.630 E13.638 E13.641
E13.649 E13.65 E13.69 E13.8 E13.9 O24.011 O24.012
O24.013 O24.019 O24.02 O24.03 O24.111 O24.112 O24.113
O24.119 O24.12 O24.13 O24.311 O24.312 O24.313 O24.319
O24.32 O24.33 O24.414 O24.415 O24.419 O24.424 O24.425
O24.429 O24.434 O24.435 O24.439 O24.811 O24.812 O24.813
O24.819 O24.82 O24.83 O24.911 O24.912 O24.913 O24.919
O24.92 O24.93 Z79.4

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