Note: Special Authority approval is required for coverage, even if a patient is already using a CGM.
Product name |
Dexcom G6 and Dexcom G7 Continuous Glucose Monitors (CGM) |
|
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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 condition) 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 |