This clinical policy outlines the criteria for medically necessary continuous glucose monitors (CGMs) for patients with diabetes mellitus. It provides information on the approved indications, contraindications, and criteria for approval.
Approved Indications
CGMs are indicated for use in patients with diabetes mellitus to monitor blood glucose levels.
Contraindications
CGMs are contraindicated in patients with implantable glucose sensors, such as the Eversense CGM system, which is considered investigational and not medically necessary due to insufficient evidence of clinical efficacy and long-term health outcomes.
Criteria for Approval
The policy provides criteria for initial and continued therapy approvals, including diagnosis of diabetes mellitus, history of problematic hypoglycemia, and adherence to a comprehensive diabetes treatment plan.
Product Availability
The policy includes information on the availability of different CGM products, including the Dexcom G6 and G7, and FreeStyle Libre 3 and 14-day Flash systems.
Manual:
Download: Heritage Nebraska Total Care Clinical Policy: Continuous Glucose Monitors
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