Fidelis Prior Authorization for Continuous Glucose Monitor

Continuous Glucose Monitoring (CGM)

If you have tried prescribing CGM in the past, but found navigating coverage and prior authorizations difficult, these additional resources outline processes, forms, and documentation for successfully ordering CGM.

Continuous Glucose Monitors (CGM) use is on the rise. Primary care practices play an important role in managing the health of patients with diabetes. Achieving glycemic targets is important in preventing short- and long-term complications, yet many patients with diabetes don't achieve recommended targets. CGM can reduce or eliminate the need for fingerstick capillary glucose testing, and provide richer information about average glycemia, hyperglycemia, hypoglycemia, and glucose variability.

Our goal is to help primary care physicians navigate prescribing and ordering CGM. If you're still having trouble, your local industry representatives or DME representatives may be helpful.

New to CGM? Start by taking the AAFP TIPS^TM on Continuous Glucose Monitoring for 2 prescribed credits. This free resource is available until April 15, 2023.

Get Started with CGM

• Determine if you and your patient feel that professional CGM or personal CGM is the best fit. Not sure? Go to AAFP TIPS^TM on Continuous Glucose Monitoring.
• CGM patient handouts are available in English and Spanish to support your conversations.
• If you and your patient decide to start professional CGM, start here.
  
• If you and your patient decide to start personal CGM, determine the type of coverage the patient has.

What Type of Coverage Does the Patient Have?

Use the tabs below to find the right scenario for your patient and how to order CGMs.Personal CGM not an option? Get more information in the Professional CGM section.

Medicare Coverage and Ordering

Medicare has eligibility requirements that must be met in order to provide coverage for personal CGM. This resource will help you navigate Medicare's eligibility requirements for initial and continuing coverage, ordering and insurance authorization, and documentation. Note that this applies to traditional Medicare, and individual Medicare managed plans or Advantage plans may vary.

Medicare Eligibility Requirements for Personal CGM

• Diagnosis of diabetes;
• Treated with 3 or more daily administrations of insulin or administers insulin continuously via pump;
• Requires frequent adjustment to the insulin treatment regimen based on glucose results (either finger stick or CGM readings);
• Seen for diabetes management in past 6 months.
• For continuing eligibility, all of the above must be met.  and Medicare requires that the treating practitioner have a visit with the patient to assess the CGM regimen and diabetes treatment plan every 6 months following initial CGM prescription.

Medicare Ordering and Continuing Coverage

Once you and your patient have determined the patient meets Medicare's requirements to cover personal CGM, follow these guidelines for ordering and authorization. Medicare coverage requires CGM to be used in conjunction with a reader. Even if a patient uses a smartphone, smartdevices are not covered by Medicare.

Ensure You Have Proper Documentation

Should reflect that patient meets Medicare's eligibility requirements for CGM coverage.

This patient has a diagnosis of diabetes; is treated with 3 or more daily administrations of insulin; requires frequent adjustment of the insulin treatment regimen based on glucose results; and has been personally seen to evaluate their diabetes treatment within the past 6 months.

Gather Information for Ordering and Insurance Authorization

• A Prescription is Required:Many EHRs support directly prescribing them as you would any medication.
• Choose a Supplier:Medicare covers CGM through the durable medical equipment (DME) benefit, not through the pharmacy benefit.
• Certificate of Medical Necessity:Save it locally so you don't have complete repeating information each time.
• Chart Notes:Some order forms also ask about frequency of glucose checks.

Important Step: Schedule a telehealth or in-person diabetes follow up within 6 months of the last visit for continuing eligibility.

How to Order CGM by Brand

Freestyle Libre 2 System

Step 1: Complete the Medicare Standard Written Order. Please note that even though this order asks for the prescribed glucose tests per day, this is no longer a Medicare requirement.

Step 2: Fax the Order and chart notes to a Freestyle Libre 2 DME supplier listed on the Medicare Standard Written Order link above.

Dexcom

Step 1: Complete the Medicare Detailed Written Order. Check the box to order the receiver even if the patient will also use their smartphone.

Step 2: Fax Order and chart notes to ASPN Pharmacy: (866) 879-8150

Medtronic CGM

Eversense

Eversense requires that the transmitter be implanted; it is recommended that you seek preauthorization for the implantation procedure before ordering.

Use the Eversense website to find information on ordering or becoming an Eversense provider.

Medicaid Coverage and Ordering

Eligibility

Medicaid coverage for CGM varies from state to state. Become familiar with your state's coverage policies. Revisit these policies periodically, as Medicaid coverage for CGM can change quite frequently. If your state has limited coverage currently, continue to monitor coverage requirements, in general, coverage for CGM has tended to expand.

State Medicaid programs range from offering broad coverage for CGM to  none at all through fee-for-service.

Questions

When exploring coverage, answer these questions:

• Does my state Medicaid program cover CGM
  • …for my patient's diabetes type?
  • …for my patient's age?
  • …through durable medical equipment or through pharmacy (or either)?
  • …if prescribed by my specialty?
• What information is needed as part of Prior Authorization?
• What other coverage criteria exist? (e.g., minimum number of finger stick glucose checks)

The resource, Expanding Medicaid Access to Continuous Glucose Monitors, contains a map and detailed table in Appendix A outlining each state's coverage for type of diabetes, population (pediatrics/adults/both), benefit from pharmacy or DME, requirements for minimum of 4 daily finger stick glucose checks, and prescriber specialty.

Ensure You Have Proper Documentation

Check your state's requirements for documentation when ordering CGM for eligible patients using state Medicaid.

Gather Information for Ordering and Insurance Authorization

Gather the documentation required. This usually includes:

• A Prescription:Many EHRs support directly prescribing them as you would any medication.
• Certificate of Medical Necessity:Save it locally so you don't have complete repeating information each time.
• Chart Notes

Eligibility and ordering guidelines for personal CGM vary state by state. An example using the state of Colorado is outlined below. Most states will follow similar steps for ordering.

Colorado Medicaid Eligibility Requirements for personal CGM: To be eligible for Colorado Medicaid coverage of personal CGM, the following requirements must be met:

• The patient self-monitors glucose at least 3 times daily (e.g. fingerstick blood sugars);
• The patient is treated with 3 or more daily administrations of insulin or administers insulin continuously via pump;
• The patient requires frequent adjustment to the insulin treatment regimen based on glucose results (either finger stick or CGM readings);
• The patient has had or will have education specific to the therapeutic CGM system being requested;
• The patient and/or their caregiver can hear and view CGM alerts;
• The patient has been seen for diabetes management in past 6 months and will continue to be seen every 6 months for this purpose;
• The patient meets the CGM manufacturer's recommendations for age range, monitoring and calibration requirements (if applicable), or has otherwise qualifying circumstances that make therapeutic CGM medically necessary.
• For continuing eligibility , all of the above must be met and Colorado Medicaid requires recertification every 6 months; be sure to schedule diabetes follow up for within 6 months of the last visit.
  

This patient has a diagnosis of diabetes; self-monitors glucose at least 3 times daily; is treated with 3 or more daily administrations of insulin or continuous insulin infusion via pump; requires frequent adjustment of the insulin treatment regimen based on glucose results; has received or will receive education specific to the CGM system being prescribed; is able themselves or has a caregiver who is able to hear and view CGM alerts and respond accordingly; has been seen to evaluate their diabetes treatment within the past 6 months; meets the manufacturer's recommendations for age range, monitoring and calibration requirements or otherwise has circumstances that make continuous glucose monitoring medically necessary.

How to Order CGM by Brand

These specific instructions follow the state of Colorado example. In other states, a DME supplier or pharmacy may be the primary contact. Check each state's Medicaid website for more information. A brand representative may be able to assist in finding the best pharmacy or DME supplier to submit.

Freestyle Libre 2 System

Step 1: Complete the Libre Certificate of Medical Necessity.

Step 2:To order a Freestyle Libre 2 if patient has a compatible smartphone:

• Freestyle Libre 2 Sensors – change sensor every 14 days, dispense 2 sensors (28-day supply), 11 refills

If patient does not have a compatible smartphone then also order:

• Freestyle Libre 2 Reader - dispense 1 reader (reader life is approx. 3 years)

Step 3:Send the Libre Certificate of Medical Necessity, chart notes, and prescription to the pharmacy or DME supplier for your state.

Dexcom

Step 1: Complete the Certificate of Medical Necessity.

Step 2: Complete the Dexcom New Patient Letter-Byers.

Step 3: Email or Fax chart notes, the Certificate of Medical Necessity, the New Patient Letter, and patient contact information (phone, address) to the pharmacy or DME supplier for your state.

Medtronic CGM

Eversense

Eversense requires that the transmitter be implanted; it is recommended that you seek preauthorization for the implantation procedure before ordering.

Become an Eversense provider and find information on ordering.

Private Insurance Coverage and Ordering

Commercial or private insurance plans likely have certain eligibility requirements that must be met in order to provide coverage for personal CGM. If your patient doesn't meet them, Professional CGM may be an option for intermittent use. This resource will help you maximize the likelihood of obtaining authorization/coverage for personal CGM for commercial/private insurance.

Eligibility

Eligibility requirements may vary widely from one payer to another, or even from one plan to another for any particular payerpayor, so specific guidance is very difficult to obtain with certainty.

Additional assistance and up-to-date resources are available at the non-profit, unaffiliated DiabetesWiseProviders Prescription Assistant Tool.

Ensure You Have Proper Documentation

• Should reflect whether patient meets payor's eligibility requirements for CGM coverage and why you feel CGM is appropriate for your patient. It may be helpful to quote and/or reference specific ADA Standard(s) for medical care in Diabetes or abridged version in either in chart notes or in prior authorization requests.
• Commercial payers generally do not require a Certificate of Medical Necessity or specific order form to prescribe to a pharmacy. However, chart notes and/or prior authorization may be requested.

• This patient has a diagnosis of diabetes; is treated with 3 or more daily administrations of insulin or continuous insulin infusion via pump; requires frequent adjustment of the insulin treatment regimen based on glucose results; and has been personally seen to evaluate their diabetes treatment within the past 6 months.
• This patient is treated with insulin and would benefit from use of a continuous glucose monitor (CGM), as recommended in the American Diabetes Association Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers (Clin Diabetes 2022;40(1):10-38): Recommendation 7.11 states that CGM should be offered for diabetes management in adults with diabetes on multiple daily injections (MDI) or CSII who are capable of using devices safely (either by themselves or with a caregiver); Recommendation 7.12 states that CGM can be used for diabetes management in adults with diabetes on basal insulin who are capable of using devices safely (either by themselves or with a caregiver). For Recommendations 7.11 and 7.12, it is further stated that the choice of device should be made based on patient circumstances, desires, and needs.
  

Gather Information for Ordering and Insurance Authorization

• A Prescription Will Be Required: Many EHRs support directly prescribing them as you would any medication.
• Choose a Supplier:Some commercial insurance plans cover CGM through the pharmacy benefit, some cover it through the durable medical equipment (DME) benefit, and some will allow either.
  

Important Step: Schedule a telehealth or in-person diabetes follow up within 6 months of the last visit for continuing eligibility.

How to Order CGM by Brand

Freestyle Libre 2 System

Check if the patient has a compatible smart devices for the Freestyle Libre 2.

To order a Freestyle Libre if patient has a compatible smartphone:

• Freestyle Libre 2 Sensors – change sensor every 14 days, dispense 2 sensors (28-day supply), 11 refills

If patient does not have a compatible smartphone, then also order:

• Freestyle Libre 2 Reader - dispense 1 reader (reader life is approx. 3 years)

Freestyle Libre 2 prescriptions are covered nearly exclusively through pharmacies under the pharmacy benefit.

• Most commercially insured patients pay $0 to $60 per month if covered.
• FreeStyle Libre program automatically limits copay to $75/month or less; if copay will be >$75, have the patient call 844-330-5535 before picking up sensors from the pharmacy

Dexcom

Check if the patient has a compatible smart devices for the Dexcom.

To order Dexcom if patient has a compatible smartphone:

• Dexcom G6 transmitter - dispense 1 per 90 days, 3 refills
• Dexcom G6 sensors - dispense 3 boxes (9 sensors) per 90 days, change sensor every 10 days, 3 refills

If patient does not have a compatible smartphone then also order:

• Dexcom G6 receiver- dispense 1, no refills

Send an electronic prescription from your EHR to ASPN Pharmacies. ASPN will determine whether the patient's particular plan covers Dexcom CGM through the pharmacy or DME benefit. ASPN will identity a participating pharmacy or DME supplier and forward the order information there for you. If you can't find ASPN in your EHR's list of pharmacies, ask your EHR administrator to add it.

ASPN Pharmacy phone: 888-489-0221, fax: 866-879-8150

Medtronic

Eversense

Eversense requires that the transmitter be implanted; it is recommended that you seek preauthorization for the implantation procedure before ordering.

Become an Eversense provider and to pursue information on ordering.

Patients Without Coverage for Personal CGM

Patients who do not meet their payer's eligibility criteria for personal CGM or those who cannot afford the full cost of obtainings a personal CGM may still benefit from CGM.

• Professional CGM–used by practices on a one-time or occasional basis for a given patient. It involves applying the CGM in the office setting and using equipment belonging to the practice.
• Self-pay for Personal CGM – patient may be willing to pay out of pocket for device and sensors. Consider cost assistance programs for eligible patients. This may be a good option for patients who have insurance, but do not meet thier payer's eligibility criteria for personal CGM.
• Sample or Trial of Personal CGM –Manufacturers may have voucher, sample, or trial programs for eligible patients. This may be a good option for patients who do not have insurance or have high deductible insurance plans.

This patient handout, What if My Continuous Glucose Monitor Is Not Covered by Insurance?, can help you discuss options with your patients.

Ensure You Have Proper Documentation

The information in your chart notes should reflect why you feel that CGM is appropriate for your patient. It may be helpful to quote and/or reference the specific ADA Standard(s) in chart notes or prior authorization requests. This may be especially helpful if pursuing low or no copay options like patient assistance programs that may require your explanation of why you recommend CGM.

• This patient has a diagnosis of diabetes; is treated with 3 or more daily administrations of insulin or continuous insulin infusion via pump; requires frequent adjustment of the insulin treatment regimen based on glucose results; and has been personally seen to evaluate their diabetes treatment within the past 6 months.
• This patient is treated with insulin and would benefit from use of a continuous glucose monitor (CGM), as recommended in the American Diabetes Association Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers (Clin Diabetes 2022;40(1):10-38): Recommendation 7.11 states that CGM should be offered for diabetes management in adults with diabetes on multiple daily injections (MDI) or CSII who are capable of using devices safely (either by themselves or with a caregiver); Recommendation 7.12 states that CGM can be used for diabetes management in adults with diabetes on basal insulin who are capable of using devices safely (either by themselves or with a caregiver). For Recommendations 7.11 and 7.12, it is further stated that the choice of device should be made based on patient circumstances, desires, and needs.

Gather Information for Ordering

• A Prescription Will Be Required:Many EHRs support directly prescribing them as you would any medication.
• Forms required for cost assistance or patient assistance (if applicable)

Cost Assistance

There are various options for limiting patient out-of-pocket costs associated with CGM. Some of these include manufacturer-based samples, vouchers, copay reduction programs, and patient assistance programs. Some of these resources are listed here:

Self-pay options:Some patients may qualify for patient assistance and/or copay reduction programs.

• FreeStyle Libre program automatically limits copay to $75/month or less; if copay will be >$75, have the patient call 844-330-5535 before picking up sensors from the pharmacy
  
• Dexcom patient assistance program
• Medtronic CGM patient assistance and Medtronic Assurance
• Eversense patient assistance

If patients do not qualify for assistance programs, options to reduce costs include:

Coupon Programs

• GoodRx or SingleCare can help find the lowest cost retail pharmacy in a geographic area. To use these sites, patients will need to register and can download an app to their smartphone. Both provide coupons to use at the pharmacy. To use, they will need to search by device name and ZIP code.
• Membership warehouses with pharmacies, like Costco and Sam's Club, often offer the lowest prices, are usually open to non-members, and may have additional significant discounts for members.

Free Trials or Samples

• Voucher for a free FreeStyle Libre2 14-day sensor
• FreeStyle Libre 2 samples can be requested from your local representative
• 30-day trial program for Medtronic Guardian Connect system
• Dexcom G6 sample kits (sensor and transmitter) can be requested from your local representative or online through the Hello Dexcom program
  

Professional CGM

Professional CGM can be extremely useful when personal CGM is not likely to be covered by insurance (e.g., if a patient's situation doesn't meet the criteria set by the insurer for personal CGM coverage). While personal CGM which belongs to the patient, professional CGM is owned by the practice and used by a given patient on a short-term basis. The CGM is applied in the office and uses a reusable reader and disposable sensor.

Advantages of Professional CGM

• Often easier path to get CGM data, especially when only desired intermittently
• May be more accurate than HbA1c in certain situations (e.g., anemia, hemoglobinopathies, CKD, etc.)
• No need or very limited need for insurance authorization
• May blind data from patient if there is concern about exposing so much to the patient
• Opportunity to cover/exceed expenses by enhancing revenue with separately billable procedures, which can be billed in addition to E/M if done on same day (details below)

Where Do I Get It?

A practice can obtain a professional CGM system and sensors by purchase through the manufacturer or a supplier.

• Freestyle Libre Pro
• Dexcom Pro

What Other Equipment is Needed?

• Reusable reader - Each system requires a reader to capture the data from the sensor. These cost about $60-65. Consider ordering a spare, or one per pod—whatever works best for your practice and flow.
• Disposable sensor - Each patient will need one. These cost about $60.

How Do I Document to Support It?

• Explain why you recommend it (like any other evaluation/test), in your progress note.
• See the Text and Macros resource for CGM Interpretation content suggestions, including dotphrase/autotext content you can use or adapt for when you review the patient data.

How Do I Apply It?

Each of the manufacturers of professional CGM systems has useful information to describe and demonstrate application.

• Freestyle Libre Pro resources
• Dexcom G6 Pro resources

How Do I Get Data from It?

Here too, each of the manufacturers of professional CGM systems has useful information to explain and demonstrate what you need to get the data.

• Freestyle Libre Pro resources
• Dexcom G6 Pro resources

How Do I Bill for It?

For traditional fee-for-service arrangements, two CPT codes can be used to bill and seek reimbursement for Pro CGM related services:

Professional CGM Start

• CPT 95250: "Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording."
• May be performed and billed as often as every 90 days for most payers
  • 4.38 RVUs; typically pays $150 Medicare, $40 Medicaid, $309-453 Commercial; the RVU and reimbursement rates for this service are meant to provide professional compensation AND to cover or mostly defray the cost of the equipment
  • Can be in addition to E/M if both E/M and Pro CGM start performed on same day

CGM Interpretation – Billable Later

• CPT 95251: "Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation, and report."
  • 1.02 RVUs; typically pays $35 Medicare, $19 Medicaid, $97-119 Commercial
  • Can be in addition to E/M if both E/M and Pro CGM interpretation performed on same day

For FQHCs and RHCs, where traditional fee-for-service billing would not support reimbursement for Pro CGM, diabetes-related grant programs can be used to purchase Pro CGM systems and sensors to help defray the equipment costs.

Supported by an educational grant to the AAFP from Abbott Diabetes Care.

simmonssuitessay68.blogspot.com

Source: https://www.aafp.org/family-physician/patient-care/care-resources/continuous-glucose-monitoring.html

Share this post