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 Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook to update changes in the Continuous Glucose Monitoring (CGM) policy.
The policy updates include the following changes from CGM client eligibility:
- Remove requirement for insulin for CGM when other criteria are met
- Add CMS criteria to qualify for CGM
- Eliminate CGM criteria for a minimal number of:
- Insulin injections per day
- Self-blood glucose monitoring tests per day
- CGM criteria includes all clients who have diabetes when other
For all diabetic clients who are not using insulin, at least one or more of the following conditions must be present:
- Frequent unexplained hypoglycaemic episodes
- Unexplained large fluctuations in daily, pre-prandial blood glucose
- Episodes of ketoacidosis or hospitalization for uncontrolled glucose
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.
- The member must be complaint with their:
- Medical regime
- Receive daily insulin administrations.
- Meet the criteria for non-insulin dependent diabetics
- Use an insulin pump
- Perform documented daily self-monitoring of blood glucose
Questions
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