What are the requirements for writing a prescription for a continuous glucose monitor 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), the prescription must document specific medical necessity criteria including the patient's diabetes type, current insulin regimen, and clinical indications such as hypoglycemia unawareness or frequent hypoglycemic episodes. 1

Patient Eligibility Requirements for Insurance Coverage

For Type 1 Diabetes Patients:

• Document that the patient has Type 1 diabetes
• Specify that the patient is on an intensive insulin regimen (multiple daily injections or insulin pump therapy)
• Note that the patient performs frequent self-monitoring of blood glucose (SMBG) prior to meals, snacks, at bedtime, and in other situations as recommended by guidelines 1

For Type 2 Diabetes Patients:

• Document that the patient is on multiple daily insulin injections
• For patients on basal insulin only: document specific challenges with glycemic control despite adherence to current regimen 1
• Note any history of severe hypoglycemia or hypoglycemia unawareness 1

Required Documentation Elements

1. Patient Diagnosis: Clearly state diabetes type and duration

2. Current Treatment Regimen:

   • Specify insulin regimen (MDI or pump)
   • Document current SMBG frequency (showing patient compliance)
   • Note current A1C level and target

3. Medical Necessity Justification:

   • Document one or more of these qualifying conditions:
     • Hypoglycemia unawareness
     • Frequent hypoglycemic episodes
     • Wide glycemic excursions
     • A1C above target despite compliance with current regimen
     • Need for improved glycemic control to prevent complications

4. Device Specifications:

   • Specify the type of CGM (real-time CGM or intermittently scanned CGM)
   • Include brand name and model
   • Specify duration (e.g., "Continuous use for 12 months")
   • Include all necessary supplies (sensors, transmitters, receivers)

5. Education Plan:

   • Document that patient will receive robust diabetes education and training on CGM use 1
   • Note that patient has demonstrated ability to use the device safely (either independently or with caregiver assistance) 1

Sample Prescription Format

Patient Name: [Patient Name]
DOB: [Date of Birth]
Diagnosis: [Type 1/Type 2] Diabetes Mellitus (ICD-10: [E10.9/E11.9])
Current A1C: [value]%
Current Insulin Regimen: [Multiple daily injections/Insulin pump therapy]

Device: [Brand name] Continuous Glucose Monitor System
Quantity: 1 receiver, [X] transmitters, [X] sensors (30-day supply)
Refills: 12

Medical Necessity:
- Patient has [Type 1/Type 2] diabetes and is on intensive insulin therapy
- Patient demonstrates [hypoglycemia unawareness/frequent hypoglycemic episodes/wide glycemic excursions/inability to achieve target A1C despite compliance]
- CGM is required to [prevent severe hypoglycemia/improve glycemic control/reduce A1C]
- Patient has been educated on proper CGM use and interpretation

Duration: 12 months

Common Pitfalls to Avoid

1. Insufficient documentation: Failing to document specific medical necessity criteria is the most common reason for insurance denial 1

2. Not specifying the complete system: Ensure your prescription includes all components (receiver, transmitter, sensors) 1

3. Missing education documentation: Insurance often requires confirmation that the patient has been educated on CGM use 1

4. Inappropriate patient selection: Document that the patient is capable of using the device safely and is motivated to use it consistently 2

5. Failure to document previous SMBG frequency: Show that the patient is already compliant with recommended monitoring 1

Remember that insurance coverage criteria may vary between payers, so it's advisable to check specific requirements with the patient's insurance provider before writing the prescription. Many CGM manufacturers also provide insurance verification services and can help navigate the coverage process.