Dexcom G6 Continuous Glucose Monitor (CGM)

Note: Special Authority approval is required for coverage, even if a patient is already using a CGM.

Product Name

Dexcom G6 Continuous Glucose Monitoring (CGM) System

Form

continuous glucose monitor (CGM)

Special Authority Criteria

Approval Period

INITIAL COVERAGE:

The patient is 2 years of age or older with diabetes mellitus (DM) and requires multiple daily injections of insulini or insulin pump therapy as part of intensive insulin therapy

AND

The patient/family/caregiver agrees to comprehensive and age-appropriate diabetes education by an interdisciplinary diabetes healthcare team and commits to regular follow-up

AND

The patient has one of the following:

Hypoglycemia unawarenessii

OR

Frequent and unpredictable hypoglycemic episodesiii

OR

Unpredictable swings in blood glucoseiv

OR

At least one functional restriction that inhibits the use of blood glucose test strips (BGTS) (e.g., dexterity, mobility, dermatological conditions)

OR

An occupation where hypoglycemia presents a significant safety risk (e.g., pilots, air traffic controllers, commercial drivers)

1 year

COVERAGE RENEWAL:

The patient with DM continues to require multiple daily injections of insulini or insulin pump therapy as part of intensive insulin therapy

AND

The patient will benefit from continued use of a continuous glucose monitor

5 years

Practitioner Exemptions

  • None

Special Notes

  • i Multiple daily injections of insulin is defined as 1 (or more) injection(s) of basal insulin and 3 (or more) injections of bolus insulin, with a minimum of at least of 4 total insulin injections per day
  • ii Hypoglycemia unawareness is defined as the inability of a patient to recognize or communicate early symptoms of hypoglycemia resulting in the inability to take corrective action to prevent severe hypoglycemic episodes
  • iii Frequent hypoglycemic episodes are defined as greater than 3 episodes per week. Unpredictable hypoglycemic episodes are defined as those that are not associated with predictable causes (e.g., physical activity, reduced food intake, acute illness, medication dosing errors)
  • iv Unpredictable swings in blood glucose is defined as variability in blood glucose levels of less than 4 mmol/L and/or greater than 10 mmol/L throughout the day that are not associated with a predictable cause (e.g., physical activity, food intake, acute illness, medication dosing errors)

Special Authority Request Form(s)