Date: April 14, 2026
Attention: Providers
Date correction will be made April 1, 2026
Call to action:The purpose of this communication is to inform providers that an error was made in the last update to the TMPPM (11/1/2025). The red text under “Key Details” below was omitted from the Continuous Glucose Monitors (CGM) Policy in the Durable Medical Equipment Handbook in the Nov. 1, 2025, version of the Texas Medicaid Provider Procedure Manual (TMPPM) Section 2.2.12.4. A correction will be made to add the language back on April 1, 2026.
How this impacts providers: For claim information, no changes were made to claim processing as no restrictions in CGM coverage were intended.
Texas Medicaid managed care organizations (MCOs) like Texas Children’s Health Plan (TCHP) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO, like TCHP. Please note, administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid and from MCO to MCO.
Below is the policy language where the error occurred:
The following initial criteria must be met for the client to qualify for the CGM benefit:
- A client must have diabetes mellitus and meet all of the following medical necessity criteria:
- The client is insulin-treated;
or
- The client has a history of problematic hypoglycemia with documentation of at least one of the following:
- Recurrent (more than one) level 2 hypoglycemic events (glucose <54 mg/dL [3.0 mmol/L] that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan;
or
- A history of one level 3 hypoglycemic event (glucose <54 mg/dL [3.0 mmol/L]) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia.
Next step for Providers: Providers are advised to review the information above to ensure alignment with the CGM policy Prior Authorization requirements. Our members/your patients are not required to be insulin treated to qualify for a CGM.
Source: Durable Medical Equipment Handbook
Previously published TCHP Communication:https://www.texaschildrenshealthplan.org/news/provider-alert/texas-medicaid-prior-authorization-updates-diabetic-equipment-and-supplies-2025
If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org.
For access to all provider alerts www.texaschildrenshealthplan.org/provideralerts.
