How do I write a prescription for a Continuous Glucose Monitor (CGM) that insurance will cover

Writing a Prescription for a Continuous Glucose Monitor (CGM) That Insurance Will Cover

To ensure insurance coverage for a Continuous Glucose Monitor (CGM), you must document specific medical necessity criteria and include required elements in your prescription based on established clinical guidelines.

Patient Selection Criteria for CGM Coverage

The American Diabetes Association guidelines clearly define which patients qualify for CGM coverage 1:

Primary Indications (Most Likely to Be Covered):

• Type 1 diabetes patients 1
• Type 2 diabetes patients on intensive insulin therapy (multiple daily injections or insulin pump) 1
• Patients with documented hypoglycemia unawareness 1
• Patients with frequent or severe hypoglycemic episodes 1
• Patients with nocturnal hypoglycemia 1

Secondary Indications (May Require Additional Documentation):

• Type 2 diabetes with unexplained severe hypoglycemia despite SMBG monitoring 1
• Patients with dramatic glycemic variability despite optimized care 1
• Patients who fear hypoglycemia and deliberately maintain high glucose levels 1
• Pregnant women with diabetes 1

Essential Prescription Elements

Your prescription must include:

1. Patient Demographics: Full name, date of birth, contact information
2. Diagnosis: Include specific ICD-10 code(s)
3. Device Specifics:
   • Type of CGM (real-time or intermittently scanned) 1
   • Brand name and model
   • Components needed (sensors, transmitter, receiver if applicable)
   • Duration of use (typically "ongoing" or "lifetime")
4. Medical Necessity Statement: Document specific qualifying criteria
5. Supplies: Specify quantity and frequency (e.g., "3 sensors per month")
6. Provider Information: Your NPI, contact information, signature and date

Sample Prescription Format

Patient: [Full Name], DOB: [Date], Contact: [Phone]
Diagnosis: [Specific diabetes type] with [qualifying condition] (ICD-10: [code])

Device: [Brand] Continuous Glucose Monitor System
Components: Sensors, Transmitter, Receiver (if applicable)
Quantity: [X] sensors per month, [X] transmitter(s) per [timeframe]
Duration: Lifetime/Ongoing use

Medical Necessity Statement: Patient has [type 1/type 2] diabetes and requires CGM due to [documented hypoglycemia unawareness/frequent hypoglycemic episodes/use of intensive insulin regimen/other specific qualifying criteria]. Patient has demonstrated ability to use the device and incorporate data into diabetes self-management.

[Provider Name, Credentials]
[NPI]
[Contact Information]
[Signature and Date]

Documentation Requirements

Insurance approval depends on thorough documentation in the patient's medical record 1:

1. Diabetes diagnosis: Type, duration, current management
2. Current therapy: Document insulin regimen or other medications
3. Blood glucose monitoring: Document frequency of current SMBG
4. Specific qualifying criteria: Document evidence of:
   • Hypoglycemia episodes (frequency, severity)
   • Hypoglycemia unawareness
   • Glycemic variability
   • Failed attempts to optimize with conventional monitoring
5. Patient education: Document that patient has received education on CGM use

Common Pitfalls to Avoid

1. Insufficient documentation: Failure to clearly document medical necessity
2. Wrong diagnosis codes: Using non-specific diabetes codes
3. Missing components: Not specifying all needed supplies
4. Inadequate follow-up plans: Not documenting how CGM data will be used
5. Incorrect patient selection: Prescribing for patients who don't meet established criteria

Insurance-Specific Considerations

Different insurers have varying requirements:

• Medicare: Requires patients to be on intensive insulin therapy (3+ injections daily or pump), perform 4+ SMBG tests daily, and have documented in-person visits 1
• Medicaid: Requirements vary by state but generally follow Medicare guidelines
• Private insurance: May have additional prior authorization requirements

By following these guidelines and thoroughly documenting medical necessity, you can maximize the likelihood of insurance approval for CGM coverage for your patients with diabetes.