Coverage for Continuous Glucose Monitor (CGM) Devices

Date: 12/20/22

Heritage Health (Medicaid):

Effective January 1, 2023, Continuous Glucose Monitor (CGM) devices will be a covered service under the Nebraska Medicaid benefit plan. The preferred CGM products will be the Freestyle Libre and Dexcom G6. Other CGM products beyond these may be requested on an individualized basis for authorization review.

Nebraska Total Care will cover CGM devices under both the Medical and Pharmacy benefits and authorization for devices can be requested via the following methods:

Medical Benefit CGM Authorization Request Process

• Request for the CGM device will be made by the provider fulfilling the order, this will typically be a Durable Medical Equipment (DME) provider
• Durable Medical Equipment (DME) providers will be responsible for gathering the clinical information from the ordering/medical providers to support the medical necessity review
• Provider will submit the clinical information along with our standard, existing Medicaid Outpatient Authorization Review Form
• Approved authorizations will be valid for a 12-month period

Pharmacy Benefit CGM Authorization Request Process

• Providers may submit CGM authorization requests through CoverMyMeds
• Approved authorizations will be valid for a 12-month period

Nebraska Total Care has a CGM clinical policy. Nebraska Total Care will review medical necessity for CGM devices utilizing their clinical policy, Nebraska Medicaid and Long-Term Care (MLTC) identified criteria and NAC 471.

If you have questions, please contact Provider Relations.