Continuous Glucose Monitor (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.
Learn about factors that might influence your decision to pursue CGM with a patient and how to ensure you are providing equitable care around CGM.
Understand key measures from CGM data and how to use shared decision making with patients to make diabetes care adjustments based on CGM data.
The AAFP has numerous resources to assist with implementing, prescribing, and interpreting data from and supporting the use of CGM in practice.
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 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.
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 enough by themselves to be covered by Medicare.
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
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.
Note: FreeStyle Libre 2 must be used for Medicare, as the FreeStyle Libre 3 is not covered by Medicare (it does not have a separate reader as required by Medicare).
Find information at FreeStyleFoundations.Abbott.
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; they will help determine a participating DME supplier.
You can also find clinic resources on Dexcom's website.
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.
Reference Medtronic's healthcare professional website for their most current resources.
Medicaid coverage for for Personal CGM varies from state to state. Become familiar with your state’s coverage policies. Revisit these policies periodically, as Medicaid coverage for for Personal 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 for Personal CGM to none at all through fee-for-service.
When exploring coverage, answer these questions:
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.
Gather the documentation required. This usually includes:
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:
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.
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.
Step 1: Complete the Libre Certificate of Medical Necessity.
Step 2: To order a Freestyle Libre 2 if patient has a compatible smartphone:
If patient does not have a compatible smartphone then also order:
Step 3: Send the Libre Certificate of Medical Necessity, chart notes, and prescription to the pharmacy or DME supplier for your state.
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.
Visit Medtronic's healthcare professional website for their most current resources.
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.
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 requirements may vary widely from one payer to another, or even from one plan to another for any particular payer, 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.
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:
If patient does not have a compatible smartphone, then also order:
Freestyle Libre 2 prescriptions are covered nearly exclusively through pharmacies under the pharmacy benefit.
Check if the patient has a compatible smart devices for the Dexcom.
To order Dexcom if patient has a compatible smartphone:
If patient does not have a compatible smartphone then also order:
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
Reference Medtronic's healthcare professional website for their most current resources.
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 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 be able to get and benefit from CGM.
This patient handout, What if My Continuous Glucose Monitor Is Not Covered by Insurance?, can help you discuss options with your patients. Click here for the Spanish version.
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.
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.
If patients do not qualify for assistance programs, options to reduce costs include:
Coupon Programs
Free Trials or Samples
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 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 disposable sensor and either a reusable reader or the patient’s smartphone (depending on the Professional CGM system and patient’s smartphone model).
This video introduces you to professional CGM and how to implement ProCGM into your practice.
A practice can obtain a professional CGM system and sensors by purchase through the manufacturer or a supplier.
Each of the manufacturers of professional CGM systems has useful information to describe and demonstrate application.
Here too, each of the manufacturers of professional CGM systems has useful information to explain and demonstrate what you need to get the data.
There are two CPT codes can be used to bill and seek payment for Professional CGM related services:
Professional CGM Startup
CGM Interpretation – Billable Later
An evaluation and management (E/M) service can only be reported on the same date as CGM services if the E/M service is medically necessary and significant and separately identifiable from the CGM service. Append modifier -25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to the E/M code when reporting CPT codes 95250 or 95251 on the same date.
Do not report CPT codes 95250 or 95251 more than once per month.
For Federally Qualified Health Centers and Rural Health Clinicss, where traditional fee-for-service billing would not support payment for Professional CGM, diabetes-related grant programs can be used to purchase Professional CGM systems and sensors to help defray the equipment costs.
*From the 2023 Medicare Physician Fee Schedule Lookup Tool (click here to search for additional detail: https://www.cms.gov/medicare/physician-fee-schedule/search). Local Medicare payment rates and requirements may vary; check with your local Medicare administrative contractor for local requirements.
Medicaid rates will vary by state.
Coverage and payment rates for private payers will vary by payer and a patient’s benefit plan. Check with your local provider relations representatives for their policies. Verify coverage for each patient.
Supported by an educational grant to the AAFP from Abbott Diabetes Care.