Glucose monitors are an indispensable diabetes management tool for providers and patients. They provide both immediate feedback and longitudinal data showing how daily activities and medications affect glucose control and symptoms. Together, providers and patients can use this information to make changes to the care plan.
There are two types of glucose monitors:
- Standard glucometers measure glucose levels at a single moment in time.
- Continuous glucose monitors (CGM) measure glucose levels continually using a sensor implanted under the skin. This provides additional information about glycemic patterns and glucose variability, including the frequency of profound hyperglycemia and hypoglycemia.
Medi-Cal: Effective January 1, 2022, Medi-Cal Rx became responsible for paying CGM claims billed under the pharmacy benefit.
- If Medi-Cal Rx denies the authorization, an authorization request submitted to HPSM will be reviewed under the HPSM medical benefit.
- Medi-Cal Rx limits CGM coverage to patients with type 1 diabetes – see the Medi-Cal Rx Provider Manual.
- Starting November 1, 2022, HPSM will only consider authorization requests for CGM under the medical benefit that are not coverable under the patient’s pharmacy benefit (Medi-Cal Rx) and meet medical criteria.
HealthWorx and Medicare: HPSM will consider covering CGM if it meets criteria under the pharmacy and medical benefit.
Medical authorization criteria for CGM coverage varies according to benefit coverage, but generally, beneficiaries must:
- Have diabetes mellitus treated with insulin three or more times per day that requires frequent blood glucose monitoring.
- Be engaged in their diabetes care.
HPSM has implemented criteria exceptions that expand CGM access to patients who do not meet the above criteria but may benefit from CGM. Clinical consideration and authorization may be granted to a patient with type 1 or type 2 diabetes managed with insulin if they meets at least one of the following criteria:
Patient has a history of severe hypoglycemia. Examples include but are not limited to:
- Diagnosed hypoglycemia unawareness.
- Refractory nocturnal hypoglycemia with at least two episodes of nocturnal hypoglycemia less than 50mg/dL in past month.
- Refractory daytime hypoglycemia with at least two episodes of hypoglycemia less than 50mg/dL in past week.
- Any severe hypoglycemia event (defined as needing assistance during hypoglycemia or hypoglycemia associated with seizures or loss of consciousness).
Patient would benefit from but is unable to use a standard glucometer. Example reasons include but are not limited to:
- Pain (peripheral neuropathy).
- Deformity or disability.
- Provider is utilizing the data to make frequent treatment adjustments (more than every three months).
- Patient has unexplained highs or lows, glucose readings discordant with measured A1c or concern for glucose variability.
- Patient is pregnant and requires multiple insulin injections.
For the prior authorization, note the following (as applicable):
- Underlying diabetes condition.
- Up-to-date medication list and laboratory results (and a comment regarding whether the patient is meeting glycemic targets).
- Number of insulin injections per day.
- Number of glucose checks per day.
- Presence of hypoglycemia unawareness or reduced awareness and/or documentation of hypoglycemia.
- Brief statement about efforts provider has undertaken, prescribed or recommended to achieve glycemic targets not being met or to decrease the frequency and/or severity of hypoglycemia.
- Evidence that the patient has tried and failed to use a standard glucometer or reasons why the patient is unable to use a standard glucometer.