Date: September 19, 2025
Attention: Providers
Effective for dates of service on or after November 1, 2025
Call to action: The purpose of this communication is to inform providers that effective for dates of service on or after November 1, 2025, Texas Medicaid will update prior authorization criteria for diabetic equipment and supplies.
How this impacts providers: Prior Authorization for Rental of External Insulin Pumps
To meet prior authorization criteria for rental of external insulin pumps, clients diagnosed with type 1 or type 2 diabetes must:
- Receive multiple daily administrations of insulin.
- Meet at least two of the following criteria:
- Elevated glycosylated hemoglobin level (HbA1c) over 7.0 percent
- History of dawn phenomenon or Somogyi phenomenon with fasting blood sugars frequently exceeding 200 mg/dl
- History of severe glycemic excursions with wide fluctuations in blood glucose
- History of problematic hypoglycemia (less than 60 mg/dL) with or without hypoglycemic unawareness
- Anticipation of pregnancy within three months
Prior Authorization for Continuous Glucose Monitors (CGMs)
For initial prior authorization of a CGM, the treating practitioner must have an in-person or Medicaid-approved telemedicine visit with the client within six months before ordering a monitor to:
- Evaluate the client’s diabetes control.
- Determine that the client meets the prior authorization criteria for a CGM.
Refer to the current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.12.7.1, “Prior Authorization,” for prior authorization criteria.
Continued Coverage Requirements
For continued CGM coverage, the treating practitioner must have an in-person or Medicaid-approved telemedicine health visit with the client every six months following the initial prescription of the CGM to document that the client adheres to the CGM regimen and diabetes treatment plan.
Next step for Providers: Providers should share this communication with their staff.
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts: www.texaschildrenshealthplan.org/provideralerts.
