TMPPM Update for Continuous Glucose Monitoring

Date: September 17, 2025

Attention: All Providers

Effective date: November 1, 2025

Call to action: Texas Children’s Health Plan (TCHP) would like inform providers that on November 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) will update prior authorization language in the Texas Medicaid Provider Procedures Manual (TMPPM), Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, section 9.2.24, “Continuous Glucose Monitoring (CGM).”

The updated prior authorization language will include the following:

• The client must be compliant with their medical regime, perform multiple daily insulin administrations, or use an insulin pump.
• The provider must document the medical necessity of CGM for the client.
• The client’s medical record must include a provider statement confirming a history of daily self-blood glucose monitoring.

Prior Authorization Criteria

Texas Medicaid will consider approving prior authorization requests for diabetic clients who are not using insulin if at least one of the following conditions is present:

• Frequent problematic hypoglycemic episodes
• Unexplained large fluctuations in daily, preprandial blood glucose
• Episodes of ketoacidosis or hospitalization for uncontrolled glucose

Note: Daily blood glucose logs are not required for prior authorization requests.

Next steps: Please share this information with your staff.

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

For access to all provider alerts,log into:
www.texaschildrenshealthplan.org/provideralerts.