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Therapeutic Continuous Glucose Monitors Become Benefit of Texas Medicaid
Attention: Primary Care Providers and Endocrinologists
Effective Date: April 1, 2020
Call to action: Texas Children’s Health Plan (TCHP) supports Texas Medicaid Health Partnership’s (TMHP) decision to include therapeutic continuous glucose monitors (CGM) as a benefit for Texas Medicaid recipients. A therapeutic CGM device requires prior authorization and is used as a replacement for self-blood glucose monitoring (SBGM). Members who have Type I or Type II diabetes may be considered for therapeutic CGM. All of the following medical necessity criteria must be met.- The member has been using a SBGM and performing frequent (at least four times per day) testing.
- Insulin injections are utilized three or more times per day or is on an insulin pump.
- The member’s insulin treatment regimen requires frequent adjustment due to SBGM or CGM testing results.
- The member is able, or has a caregiver who is able, to learn to use the device, hear and view CGM alerts and respond appropriately.
- A member with hypoglycemia unawareness or several episodes of hypoglycemia per day may also qualify for therapeutic CGM if the above criteria are not met.
- The initial order from a provider who is managing the member’s diabetes is valid for a six (6) month period.
- If a member demonstrates compliance with the use of the CGM and treatment plan, an additional six (6) month order may be submitted.
- After the first year, an order for replacement sensors, transmitter, and receiver (following frequency rules) may be submitted for a twelve (12) month period.
- The therapeutic CGM device billing code is K0554 and limited to one device per three years.
- When a therapeutic CGM device is approved, the related supplies (procedure code K0553) are also covered at once per calendar month.