K0553, Supply allowance for therapeutic continuous glucose monitor (cgm), includes all
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- I.Non-ImplantedContinuous Interstitial Glucose Monitoring Devices for Personal Use
- Use of anon-implantedcontinuous interstitial glucose monitoring device for personal use is consideredmedically necessaryfor individuals who meet the following criteria:
- Individual has been diagnosed with diabetes mellitus (any type);and
- Insulin injections are required multiple times daily or an insulin pump is used for maintenance of blood sugar control;and
- Both of the following (1 and 2):The individual or caregiver(s) demonstrates the following:An understanding of the technology, including use of the device to recognize alerts and alarms;andMotivation to use the device correctly and consistently;andContinued participation in a comprehensive diabetes treatment plan;andAnyof the following are present, despite ongoing management using self-monitoring and insulin administration regimens to optimize care:Inadequate glycemic control, demonstrated by HbA [...]
- The individual or caregiver(s) demonstrates the following:An understanding of the technology, including use of the device to recognize alerts and alarms;andMotivation to use the device correctly and consistently;andContinued participation in a comprehensive diabetes treatment plan;and
1 Active Policy
ANTHEM-CG-DME-42, CG-DME-42 Continuous Glucose Monitoring Devices
Related Codes
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