Continuous Glucose Monitoring Systems for Diabetics
Monday, February 24, 2020
Continuous glucose monitoring systems (CGMSs) allow for ongoing, real-time monitoring and recording of blood glucose levels at set intervals, which can be helpful for diabetic patients who need to closely track their blood glucose levels. Retroactive to Jan. 1, 2020, TRICARE has revised its CGMS benefit to allow for the use of U.S. Food and Drug Administration (FDA)-approved CGMSs by beneficiaries with uncontrolled diabetes. The device must be ordered by a TRICARE-authorized provider and the beneficiary must meet all coverage criteria.
TRICARE will cover therapeutic (replaces fingerstick testing) and non-therapeutic (compliments fingerstick testing) devices; however, therapeutic and non-therapeutic devices and supplies may not be billed on the same claim. Please bill per month rather than every 30 days. This will help reduce claim rejection errors for non-30-day months. Refer to TRICARE Policy Manual, Chapter 8, Section 5.3, paragraph 6.0 for specific billing guidelines.
Durable medical equipment prior authorization rules apply. If an approval is not required, you must submit documentation with the claim showing the beneficiary meets all coverage criteria. To expedite the review process, we offer a Letter of Attestation that can be attached in lieu of clinical documentation on our Letters of Attestation page.
TRICARE offers CGMS coverage for TRICARE beneficiaries who:
- Were diagnosed with diabetes prior to being prescribed the CGMS.
- Had an in-person evaluation by the ordering provider within six months prior to being prescribed the device.
- Have completed a comprehensive diabetic education program.
- Have undergone an appropriate treatment regimen, including at least three insulin injections per day or insulin pump therapy, with frequent self-adjustment of insulin doses in the last three months (except for gestational diabetes, which has no time requirement for the self-adjustment of insulin).
- Perform blood glucose self-testing on average of at least four times per day prior to initiation of CGMS therapy.
- Have at least one of the following:
- A glycosylated hemoglobin level (HBA1c) greater than 7.0% or less than 4.0%
- A history of unexplained, large fluctuations in daily glucose values before meals
- A history of early morning fasting hyperglycemia (“dawn phenomenon”)
- A history of severe glycemic excursions
- Hypoglycemic unawareness
- A history of recurrent, unexplained, severe hypoglycemic events
- A history of recurrent episodes of ketoacidosis
- Hospitalizations for uncontrolled glucose levels
- Frequent nocturnal hypoglycemia
- Pregnancy with poorly controlled diabetes or gestational diabetes
For additional benefit details on diabetic supplies, visit our Diabetic Supplies and Equipment page.