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Glucose Monitors

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:

  • Blood glucose monitors (BGMs) measure glucose levels from a small sample of blood, usually derived from a fingertip. BGM readings reflect glucose levels at a single moment in time.
  • Continuous glucose monitors (CGM) measure glucose levels in interstitial fluid every few minutes and don't require finger pricking. They work through a sensor that is implanted under the skin that transmits results to a reader. CGMs also provide previous glycemic patterns and glucose variability, frequency of profound hyperglycemia and hypoglycemia, and a prediction of future hypoglycemic events before they happen.

Benefit coverage

Coverage for glucose monitors depends on the member's insurance an how they are billed:

  • Outpatient Pharmacy Benefit: Glucose monitors obtained from retail or mail-order pharmacies. Claims under this benefit use NDC codes.
  • Medical Benefit: Glucose monitors obtained directly from healthcare professionals or DME providers. Claims under this benefit use CPT codes.

Note: Some DME providers can bill glucose monitors through either the outpatient pharmacy benefit or the medical benefit.

Below are additional details surrounding how glucose monitors are covered for HPSM members:

Outpatient Pharmacy Benefit

  • Medi-Cal: Effective January 1, 2022, Medi-Cal Rx became responsible for paying for all BGMs and CGMs billed under the pharmacy benefit for Medi-Cal members. Therefore, all claims and prior authorizations involving glucose monitors should be submitted to Magellan, the contractor that manages claims for Medi-Cal Rx.
  • HealthWorx and CareAdvantage:
    • BGM: HPSM’s preferred formulary blood glucose monitor is Fora premium v10 glucose meter, which is covered without prior authorization for all eligible members. If a member needs a different brand of blood glucose monitor, prior authorization is required with documentation provided justifying why Fora premium v10 is not appropriate.
    • CGM: HPSM’s preferred formulary continuous glucose monitor is Freestyle Libre 2 and Freestyle Libre 3. These are covered without prior authorization for all eligible members who have had an insulin claim within the past 120 days. If a member needs a different brand of continuous glucose monitor, prior authorization is required with information provided justifying why Freestyle Libre is not appropriate. For members without an insulin claim within the past 120 days, coverage of CGMs requires prior authorization. Refer to "CGM Authorization criteria" below for details on the required information.

Medical Benefit

  • Medi-Cal:
    • BGM: HPSM covers blood glucose monitors with prior authorization. The documentation provided must confirm that the member has diabetes mellitus.
    • CGM: 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. Medi-Cal Rx limits CGM coverage to patients who are insulin dependent or have  problematic hypoglycemia – see the Medi-Cal Rx Provider Manual.

HealthWorx and CareAdvantage:

  • BGM: HPSM covers blood glucose monitors with prior authorization. The documentation provided must confirm that the member has diabetes mellitus.
  • CGM: Continuous glucose monitors are covered by HPSM with an approved prior authorization. Refer to the "CGM Authorization Criteria" below for details on the required information.

Note: Blood glucose monitors covered through the medical benefit are usually provided by an HPSM in-network DME provider. See a list of DME vendors here.

Continuous Glucose Monitor (CGM) authorization criteria

Medical authorization criteria for CGM coverage varies according to benefit coverage, but generally, beneficiaries must:

  • Have diabetes mellitus treated with insulin; OR
  • Have a history of problematic hypoglycemia. Examples include but are not limited to: diagnosed hypoglycemia unawareness; refractory nocturnal hypoglycemia with at least two episodes of nocturnal hypoglycemia less than 50 mg/dL in the past month; refractory daytime hypoglycemia with at least two episodes of hypoglycemia less than 50 mg/dL in the past week; and/or any severe hypoglycemia event (defined as needing assistance of someone else during hypoglycemia associated with seizures or loss of consciousness).

Criteria exceptions

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 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.
  • Occupation.
  • Non-adherence.

Other exceptions:

  • 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.

Documentation checklist

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.