G0564, Creation of subcutaneous pocket with insertion of 365 day implantable
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation confirming that the monitor/component is malfunctioning, is no longer under warranty and cannot be repaired (required for replacement of CGM or pump/component).
- Evidence of an evaluation by the health care provider managing the diabetes within the last six months that includes a recommendation supporting continued use of a continuous glucose monitor (required for replacement of CGM or pump/component).
- For therapeutic/non-adjunctive and non-therapeutic/adjunctive CGM coverage: documentation that the device is being used according to the FDA approved indications and that the individual is on one of the specified insulin regimens (multiple daily injections; long-acting basal insulin; continuous subcutaneous external insulin pump).
- For short-term/professional CGM: documentation of difficult to control insulin-treated diabetes (e.g., hypo- or hyperglycemic episodes unresponsive to adjustments in therapy, asymptomatic nocturnal hypoglycemia) when used up to 14 days for diagnostic purposes.
Key Coverage Criteria
- A minimally invasive, continuous glucose monitoring system (CGMS) is considered medically necessary for the management of difficult to control insulin-treated diabetes mellitus (e.g., hypo- or hyperglycemic episodes unresponsive to adjustments in therapy, asymptomatic nocturnal hypoglycemia) for up to 14 days under the core medical benefits of the plan, for up to six separate sessions in any given 12-month period (CPT® code 95249,95250,95251).
- A minimally invasive, therapeutic/non-adjunctive continuous glucose monitoring system (CGMS) (HCPCS A4238, A4239, E2102, E2103), which may include sensors (HCPCS A4238, A4239, A9276), transmitters (HCPCS A4238, A4239, A9277) and reader/receiver (HCPCS A9278, E2102, E2103), is considered medically necessary for the management of type 1 or type 2 diabetes mellitus:
- - Freestyle Libre and Freestyle Libre 14 day for an individual age 18 years and older
- - Freestyle Libre 2 and Freestyle Libre 3 for an individual age 4 years and older
- - Freestyle Libre 2 Plus, Freestyle Libre 3 Plus, Dexcom G6® and Dexcom G7 for an individual age 2 years and older
- WHEN the individual is on ANY of the following insulin regimens: multiple daily injections; long-acting basal insulin (e.g. glargine, detemir, degludec, NPH); continuous subcutaneous external insulin pump.
2 Active Policies
CIGNA-0106, Diabetes Equipment and Supplies
ANTHEM-CG-DME-42, CG-DME-42 Continuous Glucose Monitoring Devices
Related Codes
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