Continuous Glucose Monitoring Systems (Revised)

By March 27, 2024 (revision date - already effective): (1) Billing team must ensure all CGMS device requests include prior authorization through Humana before claim submission. (2) Update billing system templates to require documentation of: at least 3 daily insulin injections, documented hypoglycemic unawareness OR recurrent severe hypoglycemic events (≥2 events in 30 days with blood glucose <70 mg/dL), and 30-day blood glucose logs. (3) For replacement device requests: require documentation of preceding 30-day blood glucose logs, expired manufacturer warranty, and confirmation device is non-functional (not lost/stolen/misused). (4) Flag and deny any requests for excluded technologies including fully automated closed-loop systems (MiniMed 670G when used as closed-loop), implantable glucose sensors, implantable insulin pumps, MiniMed Connect, mySentry remote monitoring systems, and non-integrated batteries. (5) Providers and prior authorization staff must verify member meets ALL criteria before submission. (6) Clinical documentation team should ensure encounter notes include blood glucose log references and specific event dates/values. Failure to follow prior authorization requirements will result in claim denials for all CGMS devices.