Glucose Monitoring-Continuous Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 03|01|2026 POLICY LAST REVIEWED: 01|07|2026 OVERVIEW This policy addresses coverage guidelines for Implantable and Non-Implantable Continuous Glucose Monitors (CGM) Home blood glucose monitors are not addressed in this policy. Please see the Related Policies Section for information related to home blood glucose monitors.
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Implantable Continuous Glucose Monitors Medicare Advantage Plans Effective 3/1/2026, prior authorization is no longer required for Medicare Advantage Plans for use of I- CGM. Commercial Products Effective 3/1/2026, prior authorization is no longer recommended for Commercial Products for use of I- CGM. Non-Implantable Continuous Glucose Monitors Medicare Advantage Plans Prior authorization is not required for non-implantable continuous glucose monitors for Medicare Advantage Plans. Commercial Products Effective 10/1/2025, Dexcom and Abbott FreeStyle Libre branded non-implantable continuous glucose monitoring devices obtained from a retail pharmacy no longer requires prior authorization through Blue Cross & Blue Shield of Rhode Island’s (BCBSRI) Pharmacy Benefit Management Program vendor.
Note: Prior authorization through BCBSRI’s Pharmacy Benefit Management Program vendor may still be required for Self-Funded Commercial Products.
Dexcom and Abbott FreeStyle Libre devices obtained from a Durable Medical Equipment Provider, or other non-implantable continuous glucose monitors that have been approved by the Food and Drug Administration (FDA) do not require prior authorization.
POLICY STATEMENT Implantable Continuous Glucose Monitors Medicare Advantage Plans and Commercial Products The use of I-CGM devices are covered.
DRAFT Medical Coverage Policy | Glucose Monitoring-Continuous

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Non-Implantable Continuous Glucose Monitors Medicare Advantage Plans The use of a non-implantable CGM device defined as “adjunctive” or “non-adjunctive” CGMs are covered.

NOTE: An adjunctive CGM requires the user to verify their glucose levels or trends displayed on a CGM with a blood glucose monitor (BGM) prior to making treatment decisions. A nonadjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to confirm testing results.

Medicare approved continuous glucose monitoring devices: • Do not require prior authorization, and • Can be obtained through either the Durable Medical Equipment (DME) or Pharmacy benefit (if the member has pharmacy benefits through BCBSRI).

Commercial Products The use of a non-implantable CGM device defined as “adjunctive” or “nonadjunctive” is a covered service.

NOTE: An adjunctive CGM requires the user to verify their glucose levels or trends displayed on a CGM with a blood glucose monitor (BGM) prior to making treatment decisions. A nonadjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to confirm testing results.

Dexcom and Abbott FreeStyle Libre branded non-implantable continuous glucose monitoring devices can be obtained through retail pharmacies through BCBSRI’s Pharmacy Benefit Management Program vendor. Effective 10/1/2025, prior authorization is not required and coverage will be through the member’s pharmacy benefit.
Note: Prior authorization through BCBSRI’s Pharmacy Benefit Management Program vendor is still required for Self-Funded Commercial Products.

These glucose monitoring devices may also be obtained through a DME provider, prior authorization is not required and is covered under the member’s Durable Medical Equipment benefit.

Medicare Advantage Plans and Commercial Products The following are not covered:
• Alcohol or peroxide (A4244, A4245), betadine or phisoHex (A4246, A4247) are not covered since these items are not required for the proper functioning of the device. • Urine test reagent strips or tablets (A4250), when used in conjunction with a CGM, are not covered. • Reflectance colorimeter devices used for measuring blood glucose levels in clinical settings are not covered as durable medical equipment for use in the home because their need for frequent professional re-calibration makes them unsuitable for home use. • Glucose monitors that are not designed for use in the home must be coded A9270 and will be denied as statutorily not covered (no benefit category). • Home blood glucose disposable monitor, including test strips (A9275) is not covered because this type of monitor does not meet the definition of DME.

Modifiers Per Centers for Medicare and Medicaid Services (CMS) guidelines, for blood glucose monitoring equipment and related supplies, the following modifiers must be added to the HCPCS supply code(s) on every claim submitted to ensure claim reimbursement: • Use modifier KX if the beneficiary is insulin treated; or, • Use modifier KS if the beneficiary is non-insulin treated. The KX modifier must not be used for a beneficiary who is not treated with insulin injections.

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Diabetic equipment and supplies are provided in accordance with Rhode Island General Law §27-20-30. The details of the law can be found in the Diabetes Self-Management Education Mandate policy. Please see the Related Policies Section.

BCBSRI maintains the right to audit the services provided to our members, regardless of the participation status of the provider. All documentation must be available to BCBSRI upon request. Failure to produce the requested information may result in denial or retraction of payment.

COVERAGE Benefits may vary by groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable office visit benefits/coverage, Diagnostic Imaging, Lab, and Machine Tests benefits/coverage, Medical Equipment, Medical Supplies and Prosthetic Devices benefits/coverage, Diabetic equipment/supplies benefits/coverage, and Pharmacy benefits/coverage.

BACKGROUND Tight glucose control in patients with diabetes has been associated with improved health outcomes. Several devices are available to measure glucose levels automatically and frequently (e.g., every 5-10 minutes). The devices measure glucose in the interstitial fluid and are approved as adjuncts to or replacements for traditional self-monitoring of blood glucose levels. Devices can be used on a long-term (continuous) or short-term (often referred to as intermittent) basis.

The advent of blood glucose monitors for use by patients in the home revolutionized the management of diabetes. Using fingersticks, patients can monitor their blood glucose levels both to determine the adequacy of hyperglycemia control and to evaluate hypoglycemic episodes. Tight glucose control, defined as a strategy involving frequent glucose checks and a target hemoglobin A1c (HbA1c) level in the range of 7%, is now considered the goal for most adults with diabetes.

Tight glucose control requires multiple daily measurements of blood glucose (ie, before meals and at bedtime), a commitment that some patients may find difficult to meet. The goal of tight glucose control has to be balanced with an associated risk of hypoglycemia. Hypoglycemia is known to be a risk in patients with type 1 diabetes. While patients with insulin-treated type 2 diabetes may also experience severe hypoglycemic episodes, there is a lower relative likelihood of severe hypoglycemia compared with patients who had type 1 diabetes. An additional limitation of periodic self-measurements of blood glucose is that glucose levels are seen in isolation, and trends in glucose levels are undetected. For example, while a diabetic patient’s fasting blood glucose level might be within normal values, hyperglycemia might be undetected postprandially, leading to elevated HbA1c values.

Management Measurements of glucose in the interstitial fluid have been developed as a technique to measure glucose values automatically throughout the day, producing data that show the trends in glucose levels. Although devices measure glucose in the interstitial fluid on a periodic rather that a continuous basis, this type of monitoring is referred to as continuous glucose monitoring (CGM).

Currently, CGM devices are of two designs: real-time CGM (rtCGM) provides real-time data on glucose level, glucose trends, direction, and rate of change and, intermittently scanned (isCGM) devices that show continuous glucose measurements retrospectively. These devices are also known as flash-glucose monitors (FGM).

Approved devices now include devices indicated for pediatric use and those with more advanced software, more frequent measurements of glucose levels, or more sophisticated alarm systems. Devices initially measured interstitial glucose every 5 to 10 minutes and stored data for download and retrospective evaluation by a clinician. With currently available devices, the intervals at which interstitial glucose is measured ranges from every 1 to 2 minutes to 5 minutes, and most provide measurements in real-time directly to patients. While CGM potentially eliminates or decreases the number of required daily fingersticks, it should be noted

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that, according to the U.S. Food and Drug Administration (FDA) labeling, some marketed monitors are not intended as an alternative to traditional self-monitoring of blood glucose levels but rather as adjuncts to monitoring, supplying additional information on glucose trends not available from self-monitoring while other devices are factory calibrated and do not require fingerstick blood glucose calibration. Devices may be used intermittently (ie, for periods of 72 hours) or continuously (ie, on a long-term basis).

Multiple CGM systems have been approved by FDA through the premarket approval process. The following is not an all-inclusive list:

Device Manufacturer Approval or Clearance Indications Continuous Glucose Monitoring System (CGMS®) MiniMed (now Medtronic) 1999 3-d use in physician's office. Not available; Minimed CGMs have largely being phased out. GlucoWatch G2® Biographer Cygnus 2001 Not available since 2008 Guardian®-RT (Real- Time) CGMS MiniMed (now Medtronic) 2005 Not available; it was a predecessor to Guardian Connect system (see below) which offered more advanced features. Dexcom® STS CGMS system Dexcom 2006 Not available; discontinued by Dexcom in 2020. Paradigm® REAL- Time System (second- generation called Paradigm Revel System) MiniMed (now Medtronic) 2006 Integrates CGM with a Paradigm insulin pump. Not available; replaced by newer Medtronic models. FreeStyle Navigator® CGM System Abbott 2008 Not available since 2011 Dexcom® G4 Platinum Dexcom 2012 Adults ≥18 y; can be worn for up to 7 d; Not available; Dexcom stopped selling the G4 Platinum and G5 Mobile systems and their components in 2020, and all support and software for these older systems ceased by the end of that year. Individuals needed to transition to newer systems, such as the Dexcom G6 or Dexcom G7, to continue using a CGM from Dexcom. 2014 Expanded to include patients with diabetes 2-17 y; Not available (see above) Dexcom®G5 Mobile CGM Dexcom 2016a Replacement for fingerstick blood glucose testing in patients ≥2 y. System requires at least 2 daily fingerstick tests for calibration purposes, but additional fingersticks are not necessary because treatment decisions can be made based on device readings; Not available since 2020 (see above)

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Dexcom® G6 Continuous Glucose Monitoring System Dexcom 2018 Children, adolescents, and adults > 2 years; indicated for the management of diabetes in persons age ≥2 years. Intended to replace fingerstick blood glucose testing for diabetes treatment decisions. Intended to autonomously communicate with digitally connected devices, including automated insulin dosing (AID) systems with 10-day wear. Dexcom G6 system is still available, but Dexcom is in the process of transitioning users to the Dexcom G7 system (see below); availability may be limited or change over time. Freestyle Libre® Flash Glucose Monitoring System Abbott 2017 Adults ≥18 y. Indicated for the management of diabetes and can be worn up to 10 days It is designed to replace blood glucose testing for diabetes treatment decisions; The FreeStyle Libre 2 and FreeStyle Libre 3 systems are being discontinued and replaced with the FreeStyle Libre 3 Plus and Freeestyle Libre 2 Plus sensors. The current FreeStyle Libre 2 and 3 sensors will be available until September 30, 2025. After this date, users will need a new prescription for the updated Plus versions. 2018 Adults ≥18 y. Extended duration of use to 14 days. Not available (see above) Freestyle Libre® 2 Flash Glucose Monitoring System Abbott 2020 Children, adolescents, and adults >2 years, including pregnant women; FreeStyle Libre 2 system is being discontinued and replaced with the Plus sensor (see above). Guardian Connect Medtronic MiniMed 2018 Adolescents and adults (14-75 years) Continuous or periodic monitoring of interstitial glucose levels. Provides real- time glucose values, trends, and alerts through a Guardian Connect app installed on a compatible consumer electronic mobile device; Not available; being discontinued by Medtronic, with the last transmitter sale on April 25, 2025, and the app removed from app stores on October 24, 2025.

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Eversense Continuous Glucose Monitoring System Senseonics 2018/2019 Adults ≥18 y. Continually measuring glucose levels up to 90 days. Use as an adjunctive device to complement, not replace, information obtained from standard home blood glucose monitoring devices. Adults ≥18 y. Continually measuring glucose levels up to 90 days. Indicated for use to replace fingerstick blood glucose measurements for diabetes treatment decisions. Historical data from the system can be interpreted to aid in providing therapy adjustments. Eversense E3 Continuous Glucose Monitoring System Senseonics 2022 Adults ≥18 y. Continually measuring glucose levels up to 180 days. The system is indicated for use to replace fingerstick blood glucose measurements for diabetes treatment decisions. The system is intended to provide real-time glucose readings, provide glucose trend information, and provide alerts for the detection and prediction of episodes of low blood glucose (hypoglycemia) and high blood glucose (hyperglycemia). The system is a prescription device. Historical data from the system can be interpreted to aid in providing therapy adjustments. These adjustments should be based on patterns and trends seen over time. Now called Eversense 365 (see below). FreeStyle Libre® 3 Continuous Glucose Monitoring System Abbott 2022 Children, adolescents, and adults >2 years, including pregnant women; FreeStyle Libre 2 and FreeStyle Libre 3 sensors will be available until September 30, 2025; being transitioned to FreeStyle Libre 3 Plus or FreeStyle Libre 2 Plus sensor Dexcom® G7 Continuous Glucose Monitoring System Dexcom 2022 Children, adolescents, and adults >2 years, including pregnant women Dexcom® Stelo Glucose BiosensorSystem (OTC) Dexcom 2024 Over-the-counter (OTC) Adults 18 years and older not on insulin Helps to detect normal (euglycemic) and low or high (dysglycemic) glucose levels. May also help the user better understand how lifestyle and behavior modification, including diet and exercise, impact glucose excursion. The user is not intended to take medical action based on the device output without consultation with a qualified healthcare professional.

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Eversense 365 Continuous Glucose Monitoring (CGM) System Senseonics 2024 Indicated for continually measuring glucose levels for up to 1 year in people (18 years or older) with diabetes. The system is indicated for use to replace fingerstick blood glucose measurements for diabetes treatment decisions. Abbott Lingo and Libre Rio Continuous Glucose Monitoring (CGM) Systems (OTC) Abbott 2024 Abbott Lingo is designed for individuals 18 years and older for overall health and wellness. Libre Rio is for adults with Type 2 diabetes who do not use insulin and typically manage their diabetes through lifestyle modifications. Dexcom G7 15-Day Continuous Glucose Monitoring (CGM) System Dexcom 2025 Adults over the age of 18 with type 1, type 2, and gestational diabetes, offering 15.5 days of wear time (including a 12- hour grace period). CGM: continuous glucose monitoring; OTC: over the counter. a As a supplement to the G4 premarketing approval.

Medicare Advantage Plans Continuous Glucose Monitors (CGM) A non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to confirm testing results. An adjunctive CGM requires the user verify their glucose levels or trends displayed on a CGM with a BGM prior to making treatment decisions. On February 28, 2022, CMS determined that both non-adjunctive and adjunctive CGMs may be classified as DME.

A CGM is intended for an individual that has been diagnosed with Diabetes mellitus. The treating practitioner should conclude that the individual or caregiver has sufficient training using a CGM, prescribed in accordance with the Food and Drug Administration (FDA) indications for use to improve glycemic control. A CGM may be prescribed for the following indications:

1. The individual is insulin-treated; or,
2. History of problematic, recurrent level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persists despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or,

3. History of one problematic level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia *Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare- approved telehealth visit with the individual to evaluate their diabetes control and determined that the criteria above is met.

   Implantable Devices As of this review, there is only one Food and Drug Administration (FDA) approved implantable therapeutic continuous glucose monitoring system (I-CGM). The Eversense Continuous Glucose Monitoring System was approved by the FDA in June 2018. This implantable CGM is a prescription device that provides real-time glucose monitoring every five minutes for up to 90 days at a time for people with diabetes. However, it is expected that additional devices are in the development and/or FDA approval process and soon may be publicly available. Hence, this policy is written to reflect coverage criteria and accompanying evidentiary review and analysis on I-CGM devices in an agnostic manner without the endorsement of any specific product.

   Medicare Advantage Plans and Commercial Products

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Insulin-treated means that the member is receiving insulin injections to treat their diabetes. Insulin does not exist in an oral form and therefore members taking oral medication to treat their diabetes are not insulin treated.

CODING

Modifiers

Per Centers for Medicare and Medicaid Services (CMS) guidelines, for blood glucose monitoring equipment and related supplies, the following modifiers MUST BE added to the HCPCS supply code(s) on every claim submitted to ensure claim reimbursement: • Use modifier KX if the member is insulin treated; or, o The KX modifier must not be used for a member who is not treated with insulin injections. • Use modifier KS if the member is non-insulin treated.

Diabetic Testing Supply Limits – Test Strips (A4253) and Lancets (A4259)

Non-Adjunctive, Non-Implantable Continuous Glucose Monitoring The following HCPCS codes represent non-adjunctive devices and supplies and are covered for Medicare Advantage Plans and Commercial Products: A4239 Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all
supplies and accessories, 1 month supply = 1 unit of service • NOTE: Up to a 90-day supply of HCPCS code A4239 may be billed and is reimbursable by BCBSRI. E2103 Non-adjunctive, non-implanted continuous glucose monitor or receiver

NOTE: The following are classified as “non-adjunctive” CGM devices. Therefore, claims for the devices and associated supplies must be filed with HCPCS codes A4239 and E2103.
• Dexcom G5 Mobile CGM • Dexcom G6 CGM System • Abbott Freestyle Libre Flash Glucose Monitoring System

NOTE FOR COMMERCIAL PRODUCTS: Dexcom and Abbott Freestyle Libre branded glucose monitoring devices are covered through BCBSRI’s Pharmacy Benefit Management Program vendor, when obtained under a Pharmacy benefit. They are also available through a Subscriber’s DME benefit. Please note that not all BCBSRI Subscribers hold pharmacy benefits through BCBSRI.

It is considered incorrect to file claims for the above non-adjunctive devices and associated supplies with HCPCS codes A9276 – A9278. BCBSRI requires that these devices and their associated supplies be billed under HCPCS codes A4239 and E2103.

Please note that BCBSRI also requires Pricing, Data Analysis and Coding contractor (PDAC) approval for devices and supplies to be considered covered. Continuous Glucose Monitor systems that have not been reviewed and listed on the Product Classification List for HCPCS code E2103 will not be covered.

Adjunctive, Non-Implantable Continuous Glucose Monitoring The following HCPCS codes represent adjunctive devices and supplies and are covered for Medicare Advantage Plans and Commercial Products:
A4238 Supply allowance for adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service Insulin Dependency Unit Limit Timeframe Insulin Dependent 500 3 months Non-Insulin Dependent 200 3 months

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• NOTE: Up to a 90-day supply of HCPCS code A4238 may be billed and is reimbursable by BCBSRI. E2102 Adjunctive, non-implanted continuous glucose monitor or receiver

It is considered incorrect to file claims for the above adjunctive devices and associated supplies with HCPCS codes A9276 – A9278. BCBSRI requires that these devices and their associated supplies be billed under HCPCS codes E2102 and A4238.

Supplies The following HCPCS codes are not covered for Medicare Advantage Plans according to CMS, and they are covered for Commercial Products. However, HCPCS codes A9276 - A9278 are not used to bill for supplies used with codes E2102 (adjunctive, non-implanted CGM or receiver) and E2103 (non-adjunctive, non- implanted CGM or receiver).
A9276 Sensor; invasive (e.g., subcutaneous), disposable, for use with non-durable medical equipment
interstitial continuous glucose monitoring system, one unit = 1 day supply A9277 Transmitter; external, for use with non-durable medical equipment interstitial continuous glucose
monitoring system
A9278 Receiver (monitor); external, for use with non-durable medical equipment interstitial continuous
glucose monitoring system
S1030 Continuous non-invasive glucose monitoring device, purchase (for physician interpretation of data,

use CPT code)
S1031 Continuous non-invasive glucose monitoring device, rental, including sensor, sensor replacement, and

download to monitor (for physician interpretation of data, use CPT code)

Implantable Continuous Glucose Monitors Medicare Advantage Plans and Commercial Products The following code(s) are covered:
0446T Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including

system activation and patient training 0447T Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision 0448T Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different

anatomic site and insertion of new implantable sensor, including system activation

NOTES:
• CPT code 0446T is globally reimbursed for both the procedure and the I-CGM device. • It is inappropriate to file an E&M (Evaluation and Management) service with CPT code 0446T unless the E&M service is a separately identifiable visit on the same day, which would be filed with modifier 25 (significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service), which will reduce payment of the E&M service by 50%. Refer to the Related Policies section for further details.

Medicare Advantage Plans and Commercial Products The following codes are covered: 95249 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a

minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of

monitor, patient training, and printout of recording
95250 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a

minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of

sensor, and printout of recording 95251 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a

minimum of 72 hours; interpretation and report

RELATED POLICIES Medicare Advantage Plans National and Local Coverage Determinations

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Artificial Pancreas Device System
Coding and Payment Guidelines / Modifiers Diabetes Self-Management Education Mandate
Durable Medical Equipment Glucose Monitoring – Home

PUBLISHED Provider Update, February 2026 Provider Update, October 2025 Provider Update, February/April/November 2024 Provider Update, April/December 2022 Provider Update, April/December 2021

REFERENCES

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2. Centers for Medicare and Medicaid Services. Local Coverage Article (LCA) for Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (A58116)
3. Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD) for Glucose Monitors (L33822)
4. Centers for Medicare and Medicaid Services. Local Coverage Article (LCA) for Glucose Monitor – Policy Article (A52464)
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51. Balaji B, Hannah W, Popova PV, et al. The Use of Continuous Glucose Monitoring in Comparison to Self-Monitoring of Blood Glucose in Gestational Diabetes: A Systematic Review. J Diabetes Sci Technol. Jul 23 2025: 19322968251357873. PMID 40698417
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