Continuous Glucose Monitor (GCM) Training
What are the CGM coverage requirements under Medicare?
CGMs are covered for members who:
• Have been diagnosed with diabetes mellitus; AND
• Have had a visit within the last six (6) months with his or her prescriber; AND
• Meets at least one of the following criteria;
◦ Member is being treated with insulin; OR
◦ Member has a history of problematic hypoglycemia with documentation of at least one of the following:
▪ Recurrent (more than one) level 2 hypoglycemic events (glucose < 54mg/dL) that persists despite multiple (more than 1) attempts to adjust medications and/or the diabetes treatment plan; OR
▪ History of one level 3 hypoglycemic event (glucose < 54 mg/dL) characterized by altered mental and/or physical state requiring third-party assistance.
All coverage requests should be submitted through the member’s medical group. For Medicare coverage policies, please see Local Coverage Determination (LCD): Glucose Monitors (L33822) and Local Coverage Article: Glucose Monitor - Policy Article (A52464).
What are the differences between non-adjunctive vs. adjunctive CGMs?
Non-adjunctive CGMs can be used as a complete replacement for traditional fingerstick blood glucose testing supplies and do not require a separate blood glucose monitor (BGM) to confirm testing results.
Adjunctive CGMs must be used in conjunction with standard finger stick tests using a home BGM to confirm testing results.
Both non-adjunctive and adjunctive CGMs are considered DME.
What are the next steps to ensure my patient receives their CGMs in a timely manner?
Submit an authorization to either:
Express Scripts (ESI)
- By phone: 1-844-424-8886, 24 hours a day, 7 days a week, TTY users: 1-800-716-3231; OR
- By fax: 1-877-251-5896 (Attention: Medicare Reviews); OR
- Electronically through the EPA portal
Once an authorization is approved, your patient will be able to obtain CGM supplies directly from an in-network pharmacy. (Find an in-network pharmacy near you using SCAN Health Plan’s Pharmacy Search Tool)
Your patient’s medical group with the appropriate CGM DME supply codes:
CGM Type | HCPCS Code | Description | Common Examples | |
Non-Adjunctive | E2103 | Receiver (monitor), dedicated, for use with non-adjunctive glucose continuous monitor system | Freestyle Libre 14 Day System FreeStyle Libre 2 Reader FreeStyle Libre 3 Reader Dexcom G5 Receiver Dexcom G6 Receiver | |
A4239 | Supply allowance for non-adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 Unit of Service | FreeStyle Libre 2 Sensors FreeStyle Libre 3 Sensors FreeStyle Libre 14 Day Dexcom G5 Sensors Dexcom G5 Transmitters Dexcom G6 Sensors Dexcom G6 Transmitters | ||
Adjunctive | E2102 | Adjunctive continuous glucose monitor or receiver | Minimed 630G System Minimed 670G System Minimed 770G System | |
A4238 | Supply allowance for adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service | Guardian Sensor 3 Guardian Sensor 3 Kit Guardian Transmitter 3 Guardian Transmitter 3 Kit Enlite Sensor Enlite Sensor Kit | ||
Commonly Used ICD-10 Diagnosis Codes (for full list refer to LCA A52464) | ||||
E10.9 | Type 1 diabetes mellitus without complications | |||
E11.65 | Type 2 diabetes mellitus with hyperglycemia | |||
E10.65 | Type 1 diabetes mellitus with hyperglycemia | |||
E11.8 | Type 2 diabetes mellitus with unspecified complications | |||
E11.9 | Type 2 diabetes mellitus without complications | |||
What kind of documentation needs to be submitted to Express Scripts (ESI) or patient’s medical group/DME vendor?
- Documentation showing that your patient meets the criteria to use CGM supplies.
- Prescription for CGM supplies (refer to HCPCS and ICD-10 codes listed above).
- Documentation showing that your patient’s diabetes diagnosis will be re-evaluated and managed every 6 months.
Additional information may be requested from the medical group.