Diabetes Testing Supplies – Continuous Glucose Monitoring (CGM) Systems Prior Authorization Criteria - Medicare Part B

Preferred therapeutic CGMs include Dexcom and Freestyle Libre

PA applies to non-preferred products only

Non-preferred continuous glucose monitoring (CGM) systems will be approved when ALL of the following are met:

1. The patient has diabetes mellitus

AND

2. ONE of the following:

A. The prescriber has indicated that the patient had an in-person visit or telehealth visit to evaluate their diabetes condition within six (6) months prior to ordering the CGM

OR

B. If previously approved through the plan’s Prior Authorization criteria, the prescriber has indicated that the patient has had an in-person visit or telehealth visit to assess adherence to their CGM regimen and diabetes treatment plan

AND

3. The prescriber has indicated the patient has failed or has limitations of use to the preferred CGMs

Length of approval: 12 months

Notes:

• See LCD L33822 for additional coverage criteria