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TRICARE Policy Manual 6010.60-M, April 1, 2015
Other Services
Chapter 8
Section 5.3
Continuous Glucose Monitoring System (CGMS) Devices
Issue Date:  December 15, 2009
Authority:  32 CFR 199
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-29, August 9, 2018
1.0  CPT Procedure Codes
95250, 95251, 0446T-0448T
2.0  HCPCS Codes
A9276 - A9278, K0553, K0554, S1030, S1031
A CGMS is a medical device used to monitor patients with diabetes mellitus. These devices, which consist of an external receiver, external transmitter, and a subcutaneously placed sensor, monitor diabetic patients by providing the physician and/or patient with periodic measurements of glucose levels in interstitial fluid. CGMS devices are usually prescribed to diabetic patients whose diabetes is not sufficiently controlled with standard diabetic medical regimens. These devices are intended only to supplement, not replace, blood glucose readings obtained from standard fingerstick glucose meters and test strips.
U.S. Food and Drug Administration (FDA) approved CGMS devices (i.e., MiniMed CGMS® System Gold™, MiniMed Guardian® Real Time System) (CPT procedure codes 95250, 95251, 0446T-0448T) may be cost-shared ONLY when it is documented that the recipient of the device is required to perform at least four self-monitoring blood glucose checks daily and is compliant with recommended medical regimens.
4.1  Short-term (up to 72-hour), intermittent (up to six times per year) use of a CGMS device may be covered for type I diabetic beneficiaries age seven years and over (or consistent with device labeling) when the beneficiary has completed a comprehensive diabetic education program, there is documentation of appropriate modification in insulin regimen, and the physician documents any one of the following:
4.1.1  Glycosylated hemoglobin level (HBA1c) is greater than 9.0% or less than 4.0%;
4.1.2  History of unexplained large fluctuations in daily glucose values before meals (greater than 150 mg/dl);
4.1.3  History of early morning fasting hyperglycemia (“dawn phenomenon”);
4.1.4  History of severe glycemic excursions; or
4.1.5  Hypoglycemic unawareness.
4.2  Long-term (greater than 72-hour, continuous or periodic) use of a CGMS device (includes transmitter, receiver, and sensors), may be covered for beneficiaries who meet the criteria for short-term use and the ordering physician documents any one or more of the following:
4.2.1  History of recurrent, unexplained, severe hypoglycemic events or hypoglycemic unawareness (i.e., blood glucose less than 50 mg/dl);
4.2.2  History of recurrent episodes of ketoacidosis;
4.2.3  Hospitalizations for uncontrolled glucose levels;
4.2.4  Frequent nocturnal hypoglycemia; or
4.2.5  The beneficiary is pregnant and has poorly controlled type I diabetes or gestational diabetes.
5.1  Use of a CGMS device for any condition or indication NOT included above.
5.2  Use of a CGMS device that is NOT FDA approved.
6.0  Effective Dates
6.1  December 1, 2008.
6.2  January 1, 2017 for CGMS (CPT procedure codes 0446T-0448T).
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