Does a BadgerCare Standard plan cover a continuous glucose monitor (CGM) for a patient with type 2 diabetes (DMt2) who is currently taking Metformin (Metformin hydrochloride) 2000 mg daily, Lantus (Insulin glargine), and Mounjaro (Tirzepatide) 10 mg weekly, and has a last CGM prescription from over a year ago for Freestyle Freedom Lite without the name of the CGM included?

CGM Coverage Decision for BadgerCare Standard Patient with Type 2 Diabetes

This prior authorization request should be DENIED as currently submitted because the patient does not meet the required prescription documentation criteria specified by ForwardHealth Topics #19817 and #17897.

Critical Missing Documentation

The fundamental issue is that the prescription from the most recent visit does not include the name of the specific continuous glucose monitor being prescribed, which is an explicit requirement for coverage under both applicable ForwardHealth policies 1.

Specific Policy Requirements Not Met:

• Topic #19817 requires: "The member has a written prescription dated within the last 12 months from a qualified health care professional on the member's medical team, including the name of the continuous glucose monitor prescribed" 1
• Topic #17897 requires: "The prescription is written by a qualified health care professional who is managing the member's diabetes, is dated within the last 12 months, and includes the name of the prescribed continuous glucose monitor" 1
• The last prescription found in the chart with a CGM name (Freestyle Freedom Lite) is from a date over 12 months ago, making it expired for coverage purposes 1
• The recent prescription from the clinical visit does not specify which CGM device is being requested 1

Clinical Appropriateness Assessment

While the documentation is insufficient, it is worth noting that this patient would likely meet clinical criteria for CGM coverage based on their diabetes management regimen:

Supporting Clinical Factors:

• Patient is on intensive insulin therapy with both basal insulin (Lantus/insulin glargine) and a GLP-1/GIP receptor agonist (Mounjaro/tirzepatide 10 mg weekly) 2, 3
• Type 2 diabetes patients on intensive insulin therapy are appropriate candidates for CGM according to Chinese Clinical Guidelines 1
• The combination of Mounjaro with basal insulin represents an intensified regimen where CGM can provide valuable glycemic monitoring 2, 3
• CGM is particularly beneficial for patients on multiple glucose-lowering medications to detect hypoglycemia and optimize therapy 1

Clinical Context of Current Medications:

• Tirzepatide (Mounjaro) has demonstrated significant HbA1c reductions (-2.43% to -2.58% at 52 weeks) when used in type 2 diabetes 2
• When tirzepatide is added to basal insulin, hypoglycemia rates are lower than with prandial insulin (0.4 vs 4.4 events per patient-year), but CGM remains valuable for detecting asymptomatic hypoglycemia 3
• The patient's regimen of metformin 2000 mg daily plus basal insulin plus tirzepatide represents a complex medication profile that benefits from continuous glucose monitoring 1

Required Actions for Approval

To obtain coverage, the ordering physician must submit a NEW prescription that includes:

1. The specific name of the CGM device being prescribed (e.g., Dexcom G6, Freestyle Libre 2, etc.) 1
2. Date within the last 12 months from the prescription date 1
3. Written by the qualified healthcare professional managing the patient's diabetes (the Clinical Pharmacist or prescribing physician) 1

Additional Considerations for Resubmission:

• The prescription should specify whether this is a real-time CGM (rtCGM) or intermittently scanned CGM (isCGM), as both are appropriate for type 2 diabetes patients on intensive insulin therapy 1
• FDA-cleared integrated CGM (iCGM) systems are preferred as they are nonadjunctive and can directly inform insulin dosing decisions without requiring fingerstick confirmation 4
• Ensure uninterrupted access to CGM supplies once approved, as interruption of CGM use is associated with worsening glycemic outcomes and increased adverse events 5

Coverage Decision Rationale

The denial is based solely on administrative/documentation deficiencies, NOT on lack of clinical appropriateness 1. The patient's clinical profile—type 2 diabetes on intensive therapy with basal insulin and tirzepatide—represents an appropriate indication for CGM use according to established guidelines 1.

Policy Framework:

• ForwardHealth HMOs have the option to require prior authorization for CGM devices 1
• When PA is required, all documentation criteria must be met exactly as specified in the policy 1
• The 12-month prescription requirement ensures current clinical oversight and appropriate device selection 1

Once a compliant prescription with the CGM device name is obtained and resubmitted, this patient should qualify for coverage based on their intensive insulin therapy regimen 1.