Covered Services

Covered Services A. The Division of Medicaid covers: 1. A continuous glucose monitoring (CGM) service when medically necessary, prior authorized by the UM/QIO, Division of Medicaid or designee, ordered by the physician who is actively managing the beneficiary’s diabetes and the beneficiary meets all of the following criteria: a) Has an established diagnosis of type I or type II diabetes mellitus that is poorly controlled as defined below: 1) Unexplained hypoglycemic episodes, 2) Nocturnal hypoglycemic episode(s), 3) Hypoglycemic unawareness and/or frequent hypoglycemic episodes leading to impairments in activities of daily living, 4) Suspected postprandial hyperglycemia, 5) Recurrent diabetic ketoacidosis, or 6) Unable to achieve optimum glycemic control as defined by the most current version of the American Diabetes Association (ADA). b) Be able, or have a caregiver who is able, to hear and view CGM alerts and respond appropriately. c) Has documented self-monitoring of blood glucose at least four (4) times per day. d) Requires insulin injections three (3) or more times per day or requires the use of an insulin pump for maintenance of blood glucose control. e) Requires frequent adjustment to insulin treatment regimen based on blood glucose testing results, f) Had an in-person visit with the ordering physician within six (6) months prior to ordering to evaluate their diabetes control and determined that criteria (1-4) above are met, g) Has an in-person visit every six (6) months following the prescription of the CGM to assess adherence to the CGM regimen and diabetes treatment plan. 2. CGM service only when the blood glucose data is obtained from a Federal Drug Administration (FDA) approved durable medical equipment (DME) medical device for home use. B. The Division of Medicaid does not require the provider to have a face-to-face office visit with the beneficiary to download, review and interpret the blood glucose data.