01/29/2024
What is new
Effective February 1, 2024, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual (TMPPM) in the Durable Medical Equipment Handbook to add changes in the Continuous Glucose Monitoring (CGM) policy.
Changes of Criteria
The policy updates include the following changes for CGM coverage changes:
- Removal of the insulin dependence requirement for CGM eligibility when other criteria are met.
- New criteria outlined for non-insulin treated diabetics for CGM eligibility aligning with CMS
- Eliminating a minimal number of insulin injections per day.
- Eliminating a minimal number of self-blood glucose monitoring tests per day.
- Outlining visit requirements for initial and follow up visits for CGM utilization which may include a telehealth visit.
- The following initial criteria must be met for the patient to qualify for the CGM benefit:
- A patient must have diabetes mellitus and meet one of the following medical necessity criteria:
- The patient is treated with insulin.
- The patient 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 medications or modify the diabetes treatment plan.
- A history of one level 3 hypoglycemic event (glucose <54 mg/dL [3.0 mmol/L]) characterized by altered mental or physical state requiring third-party assistance for the treatment of hypoglycemia.
- A patient with unawareness of hypoglycemia or several episodes of hypoglycemia a day also qualifies for the CGM benefit if the patient does not meet the criteria outlined above.
- The patient’s treating practitioner has concluded that the patient or the patient’s caregiver has sufficient training using the CGM prescribed, as evidenced by providing a prescription for the appropriate supplies and frequency of blood glucose testing.
- The CGM is prescribed in accordance with its U.S. Food and Drug Administration (FDA) indications for use.
Billing Instructions
Within six months prior to ordering the CGM, the treating practitioner must have an in-person or Medicaid-approved telehealth visit with the patient to evaluate their diabetes control and determine that the criteria above are met.
For continued CGM coverage, the treating practitioner must have an in-person or Medicaid approved telehealth visit with the patient every six months following the initial prescription of the CGM to document adherence to the CGM regimen and diabetes treatment plan.
In Fee-for-Service Medicaid, prior authorization is not required for CMG supplies once a device is approved. When a CGM procedure code (E2102 or E2103) is covered, the related supply allowance (procedure code A4238 or A4239) is also covered.
Providers, for questions or additional information, please:
- Contact your BCBSTX Medicaid Network Representative at 1-855-212-1615
- Submit via email Texas Medicaid Network Department
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.