Does K0553 require prior authorization?

Yes, K0553 requires prior authorization (high confidence). Code explicitly requires prior authorization.

`K0553`, Supply allowance for therapeutic continuous glucose monitor (cgm), includes all

HCPCS/CPT

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

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

ANTHEM-CG-DME-42, Continuous Glucose Monitoring Devices

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

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