Notification

Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)


Notification Issue Date: 04/04/2018

This version of the policy will become effective 05/07/2018.

This policy has been updated to remove the information regarding long-term continuous glucose monitoring (CGM) and add this information into the Insulin Pumps Policy # 05.00.79.



Medical Policy Bulletin


Title:Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)

Policy #:05.00.24q

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

SHORT-TERM INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM
Use of an FDA-approved short-term (i.e., 72-hour minimum) interstitial continuous glucose monitoring system (CGMS) for detecting trends and patterns in glucose levels is considered medically necessary and, therefore, covered, as a professional service, for individuals who meet one of the following criteria:
  • The individual is pregnant with type I or type II diabetes that requires insulin therapy.
  • The individual is pregnant and develops gestational diabetes, defined as any degree of glucose intolerance with onset or first recognition during pregnancy, which requires insulin therapy.
  • The individual has type I diabetes and requires determination of basal insulin level measurements prior to insulin pump initiation.
  • The individual has type I or type II diabetes and documentation of all of the following:
    • The individual has received diabetes self-management education and instruction from a health care professional with expertise in the management of diabetes.
    • The individual has a documented average of at least three glucose self-tests per day during the previous month.
    • The individual has a documented history of poorly controlled diabetes (i.e., severe ketosis or hypoglycemic episodes without experiencing warning and recognition of symptoms or hypoglycemic unawareness).
    • The individual is on an intensive insulin regimen, requiring two or more insulin injections per day, or utilizes an insulin pump.
    • The individual has one or more of the following while on an intensive insulin regimen:
      • Glycated hemoglobin (HbA1c) values less than four or greater than nine
      • Unexplained large fluctuations in daily glucose values before meals
      • Unexplained frequent hypoglycemic attacks
      • Episodes of ketoacidosis or hospitalizations for significantly elevated glucose levels
Short-term interstitial CGMS monitoring must be reported only once per monitoring period, regardless of the number of days involved. Continuous interstitial glucose monitoring must be performed for a minimum of 72 hours to show glucose trends effectively.

For short-term interstitial CGMS devices, a monitoring period of less than 72 hours is considered not medically necessary and, therefore, not covered.

Short-term interstitial CGMS monitoring is intended only for periodic or occasional testing and to supplement, not replace, self-testing of blood glucose.

All other uses for a short-term interstitial CGMS are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

The use of a short-term interstitial continuous glucose monitoring system (CGMS) that is a provider-owned device loaned to an individual for a minimum of 72 hours is anticipated to be used no more than once every six months.

Interstitial CGMSs have been approved by the US Food and Drug Administration (FDA) for adult and pediatric individuals with diabetes.

Any individual who uses a CGMS should also receive a personalized plan for ongoing diabetes management, which should be the result of discussion and collaboration between the individual and their health care provider. This plan should include targeted goals, outcomes, and updates; it should also reflect the individual's active role in their current diabetes management status.

Successful operation of a CGMS requires visual and auditory acuity. Therefore, CGMS and threshold suspend devices are not recommended for individuals with impaired vision or hearing that would not allow for full recognition of the device monitor, signals, and alarms.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, interstitial CGMSs are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Description

Blood glucose monitoring has been shown to be an important tool in maintaining glycemic control and avoiding complications of diabetes.

INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM

Interstitial continuous glucose monitoring systems (CGMSs) are minimally invasive devices that record interstitial glucose levels every one to five minutes. Many of the newer generation devices incorporate a CGMS with an insulin pump. In contrast to traditional self-monitoring of blood glucose, a CGMS automatically measures interstitial glucose levels and uses this data to reveal trends in glucose measurement. A CGMS also uses an alarm to alert the individual when sudden, or potentially harmful, changes in blood sugar levels occur.

Interstitial CGMSs are intended to supplement, not replace, self-monitoring of blood glucose.

SHORT-TERM INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM

A short-term interstitial CGMS is a health care provider--owned device that is loaned to an individual who wears it for a minimum of 72 hours. The individual calibrates the system at least twice a day by entering their glucose measurement obtained from a traditional blood glucose monitor.

The detailed glucose trend and pattern information is collected by the device and reviewed by a professional health care provider. Based on this information, adjustments may be made to the individual's medication, diet, or exercise regimen. Short-term interstitial CGMSs are indicated for use in individuals with diabetes who demonstrate marked changes in status, as evidenced by unexplained glycemic fluctuations. These devices can also be used periodically to confirm the status of current diabetic therapy. They are intended only for occasional testing and to supplement, not replace, self-testing of blood glucose.
References


Agrawal P, Welsh J, et al. Usage and effectiveness of the low glucose suspend feature of the medtronic Paradigm Veo Insulin Pump. Diabetes Sci and Tech. 2011;5:1137-1141.

Agrawal P, Zhong A, Welsh JB, et al. Retrospective analysis of the real-world use of the threshold suspend feature of sensor-augmented insulin pumps. Diabetes Technol Ther. 2015;17(5):316-319.

AHRQ Systematic Review Surveillance Program CER #57: Methods for Insulin Delivery and Glucose Monitoring: Comparative Effectiveness Original Release Date: July 2012 Surveillance Report: February 2016. Available at:
https://effectivehealthcare.ahrq.gov/ehc/products/242/2182/insulin-blood-sugar-surveillance-160215.pdf. Accessed April 17, 2017.

American Diabetes Association. Hypoglycemia. [American Diabetes Association Web site]. Available at: http://www.diabetes.org/type-1-diabetes/hypoglycemia.jsp. Accessed March 24, 2016.

American Diabetes A. 7. Approaches to glycemic treatment. Diabetes Care. 2015;38 Suppl:S41-48.

American Diabetes Association. Standards of Medical Care in Diabetes 2014. Diabetes Care. 2014;37(Supplement 1):S14-S80.

Bailey KJ, Little JP, Jung ME. Self-monitoring using continuous glucose monitors with real-time feedback improves exercise adherence in individuals with impaired blood glucose: a pilot study. Diabetes Technol Ther. 2016;18(3):185-193.

Battelino T, Conget I, Olsen B, et al. The use and efficacy of continuous glucose monitoring in type1 diabetes treated with insulin pump therapy: a randomised controlled trial. Diabetologia. 2012; 55(12):3155-62.

Bergenstal RM, Klonoff DC, Garg SK, et al. Threshold-based insulin-pump interruption for reduction of hypoglycemia. N Engl J Med. 2013;369(3):224-232.

Bergenstal RM, Tamborlane WV, Ahmann A, et al.; STAR 3 Study Group. Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med. 2010;363(4):311-20.

Blue Cross and Blue Shield Association, Technology Evaluation Center (TEC). Artificial Pancreas Device Systems. TEC Assessments. 2013;Volume 28, Tab 14.

Blue Cross and Blue Shield Technology Evaluation Center (TEC). Use of Intermittent or Continuous Interstitial Fluid Glucose Monitoring in Patients with Diabetes Mellitus. TEC Assessments 2003; Volume 18, Tab 16.

Buckingham BA, Cameron F, Calhoun P, et al. Outpatient safety assessment of an in-home predictive low-glucose suspend system with type 1 diabetes subjects at elevated risk of nocturnal hypoglycemia. Diabetes Technol Ther.2013;15(8):622-7.

Centers for Disease Control and Prevention (CDC). National Diabetes Statistics Report, 2014. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available at:
http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
Accessed March 24, 2016.

Choudhary P, Ramasamy S, Green L, et al. Real-time continuous glucose monitoring significantly reduces severe hypoglycemia in hypoglycemia-unaware patients with type 1 diabetes. Diabetes Care. 2013 Oct 8. [Epub ahead of print]

Choudhary P, Shin J, Wang Y, et al. Insulin pump therapy with automated insulin suspension in response to hypoglycemia: reduction in nocturnal hypoglycemia in those at greatest risk. Diabetes Care. 2011;34(9):2023-5.

Danne T, Kordonouri O, Holder M, et al. Prevention of hypoglycemia by using low glucose suspend function in sensor-augmented pump therapy. Diabetes Technol Ther. 2011;13(11):1129-34.

Deiss D, Bolinder J, Riveline J, et al. Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring. Diabetes Care. 2006:29(12):2730-2732.

Dexcom. Introducing the Dexcom G5 Mobile CGM System. 2017. Available at:
https://www.dexcom.com/get-started-cgm?utm_source=website&utm_medium=cpc&utm_campaign=70133000001LlpgAAC&gclid=CJ3609qviNMCFc6EswodnOwLUA Accessed April 20, 2017.

Diabetes Research in Children Network (DirecNet) Study Group. The Accuracy of the CGMS™ in Children with Type 1 Diabetes: Results of the Diabetes Research in Children Network (DirecNet) Accuracy Study. Diabetes Technol Ther. Author manuscript; available in PMC 2008 February 22. Diabetes Technol Ther. 2003; 5(5):781–789.

Ehrhardt NM, Chellappa M, Walker MS, et al. The effect of real-time continuous glucose monitoring on glycemic control in patients with type 2 diabetes mellitus. J Diabetes Sci Technol. 2011;5(3):668-75.

Endocrine Society. Correspondence to FDA RE: Draft Guidance for Industry and Food and Drug Administration Staff: The Content of Investigational Device Exemption and Premarket Approval Applications for Artificial Pancreas Device Systems. March 5, 2012. Available at:
https://www.endocrine.org/~/media/endosociety/Files/Advocacy%20and%20Outreach/Society%20Letters/SocietyCommentstoFDAonArtificialPancreasDraftGuidance.pdf. Accessed April 5, 2017.

Floyd B, Chandra P, Hall S, et al. Comparative analysis of the efficacy of continuous monitoring and self-monitoring of blood glucose in type 1 diabetes mellitus. J Diabetes Sci Technol. 2012; 6(5):1094-102.

Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care. 2011:34(Supp 1):S89-S96.

Gandhi GY, Kovalaske M, Kudva Y, et al. Efficacy of continuous glucose monitoring in improved glycemic control and reducing hypoglycemia: a systematic review and meta-analysis of randomized trials. J Diabetes Sci Technol. 2011;5(4):952-65.

Garg S, Brazg RL, Bailey TS, et al. Reduction in duration of hypoglycemia by automatic suspension of insulin delivery: the in-clinic ASPIRE study. Diabetes Technol Ther. 2012;14(3):205-209.

Garg S, Zisser H, Schwartz S, et al. Improvement in glycemic excursions with a transcutaneous, real-time continuous glucose sensor: a randomized controlled trial. Diabetes Care. 2006;29(1):44-50.

Gehlaut RR, Dogbey GY, Schwartz FL, et al. Hypoglycemia in type 2 diabetes--more common than you think: a continuous glucose monitoring study. J Diabetes Sci Technol. 2015;9(5):999-1005.

Gingras V, Rabasa-Lhoret R, Messier V, et al. Efficacy of dual-hormone artificial pancreas to alleviate the carbohydrate-counting burden of type 1 diabetes: A randomized crossover trial. Diabetes Metab. 2016;42(1):47-54.

Guillod L, Comte-Perret S, Monbaron D, et al. Nocturnal hypoglycaemias in type 1 diabetic patients: what can we learn with continuous glucose monitoring? Diabetes Metab. 2007;33(5):360-365.

Haidar A, Legault L, Messier V, et al. Comparison of dual-hormone artificial pancreas, single-hormone artificial pancreas, and conventional insulin pump therapy for glycaemic control in patients with type 1 diabetes: an open-label randomised controlled crossover trial. Lancet Diabetes Endocrinol. 2015:17-26.

Halvorson M, Carpenter S, Kaiserman K, Kaufman FR. A pilot trial in pediatrics with the sensor-augmented pump: combining real-time continuous glucose monitoring with the insulin pump. J Pediatr. 2007;150(1):103-105.

Hovorka R, Elleri D, Thabit H, et al. Overnight Closed-Loop Insulin Delivery in Young People With Type 1 Diabetes: A Free-Living, Randomized Clinical Trial. Diabetes Care. 2014 May; 37(5): 1204–1211. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3994941/. Accessed April 5, 2017.

Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med. 2008;359(14):1464-1476.

Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. The effect of continuous glucose monitoring in well-controlled type 1 diabetes. Diabetes Care. 2009;32(8):1378-83.

Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. Effectiveness of continuous glucose monitoring in a clinical care environment. Diabetes Care. 2010; 33(1):17-22.

Klonoff DC, Buckingham B, Christiansen JS, et al. Continuous glucose monitoring: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab.2011;96(10):2968-79.

Langendam M, Luijf YM, Hooft L, et al. Continuous glucose monitoring systems for type 1 diabetes mellitus. Cochrane Database Syst Rev. 2012;1:CD008101.

Little SA, Leelarathna L, Walkinshaw E, et al. Recovery of hypoglycemia awareness in long-standing type 1 diabetes: a multicenter 2 x 2 factorial randomized controlled trial comparing insulin pump with multiple daily injections and continuous with conventional glucose self-monitoring (HypoCOMPaSS). Diabetes Care. 2014;37(8):2114-2122.

Ly TT, Nicholas JA, Retterath A, et al. Analysis of glucose responses to automated insulin suspension with sensor-augmented pump therapy. Diabetes Care. 2012;35(7):1462-5.

Ly TT, Nicholas JA, Retterath A, et al. Effect of sensor-augmented insulin pump therapy and automated insulin suspension vs standard insulin pump therapy on hypoglycemia in patients with type 1 diabetes: a randomized clinical trial. JAMA. 2013;310(12):1240-7.

Mauras N, Beck R, Xing D, et al. A randomized clinical trial to assess the efficacy and safety of real-time continuous glucose monitoring in the management of type 1 diabetes in young children aged 4 to <10 years. Diabetes Care. 2012;35(2):204-210.

Medtronic (Manufacturer website).https://professional.medtronicdiabetes.com/minimed-530-g. Accessed March 24, 2016.

Murphy HR, Rayman G, Lewis K, et al. Effectiveness of continuous glucose monitoring in pregnant women with diabetes: randomised clinical trial. BMJ. 2008;337:a1680.

National Center for Health and Care Excellence (NICE). Type 1 diabetes in adults: diagnosis and management. Aug 2015; https://www.nice.org.uk/guidance/ng17?unlid=382286372016220232952. Accessed April 17, 2017.

Newman SP, Cooke D, Casbard A, et al. A randomised controlled trial to compare minimally invasive glucose monitoring devices with conventional monitoring in the management of insulin-treated diabetes mellitus (MITRE). Health Technol Assess. 2009;13(28):iii-iv, 1-194.

Nimri R, Danne T, Kordonouri O, et al. The "Glucositter" overnight automated closed loop system for type 1 diabetes: a randomized crossover trial. Pediatr Diabetes. 2013;14(3):159-167.

Nimri R, Muller I, Atlas E, et al. Night glucose control with MD-Logic artificial pancreas in home setting: a single blind, randomized crossover trial-interim analysis. Pediatr Diabetes. 2014;15(2):91-9.

NÝrgaard K, Scaramuzza A, Bratina N, et al.; Interpret Study Group. Routine sensor-augmented pump therapy in type 1 diabetes: the INTERPRET study. Diabetes Technol Ther. 2013;15(4):273-80.

Pazos-Couselo M, Garcia-Lopez JM, Gonzalez-Rodriguez M, et al. High incidence of hypoglycemia in stable insulin-treated type 2 diabetes mellitus: continuous glucose monitoring vs. self-monitored blood glucose. Observational prospective study. Can J Diabetes. 2015;39(5):428-433.

Phillip M, Battelino T, Atlas E et al. Nocturnal glucose control with an artificial pancreas at a diabetes camp. N Engl J Med. 2013; 368(9):824-33.

Poolsup N, Suksomboon N, Kyaw AM. Systematic review and meta-analysis of the effectiveness of continuous glucose monitoring (CGM) on glucose control in diabetes. Diabetol Metab Syndr. 2013;5(1):39.

Rodbard HW, Blonde L, Braithwaite SS, et al. American Academy of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13(Suppl1):1-68.

Secher AL, Ringholm L, Andersen HU, et al. The Effect of Real-Time Continuous Glucose Monitoring in Pregnant Women With Diabetes: A randomized controlled trial. Diabetes Care. 2013 [Epub ahead of print].

Sequeira PA, Montoya L, Ruelas V, et al. Continuous glucose monitoring pilot in low-income type 1 diabetes patients. Diabetes Technol Ther. 2013;15(10):855-858.

Tanenberg R, Bode B, Lane W, et al. Use of continuous glucose monitoring system to guide therapy in patients with insulin-treated diabetes: a randomized controlled trial. Mayo Clin Proc. 2004;79(12):1521-1526.

Tavris DR, Shoaibi A. The public health impact of the MiniMed Continuous Glucose Monitoring System (CGMS) - an assessment of the literature. Diabetes Technol Ther. 2004;6(4):518-522.

Thabit H, Elleri D, Leelarathna L, et al. Unsupervised overnight closed loop insulin delivery during free living: analysis of randomised cross-over home studies in adults and adolescents with type 1 diabetes. Lancet. 2015;385 Suppl 1:S96.

Tubiana-Rufi N, Riveline JP, Dardari D. Real-time continuous glucose monitoring using Guardian RT: from research to clinical practice. Diabetes Metab. 2007;33(6):415-420.

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US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Dexcom G4 PLATINUM Continuous Glucose Monitoring Syste. [FDA Web site]. 10/05/2012. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf12/p120005a.pdf. Accessed April 5, 2017.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. DexCom™ STS™ Continuous Glucose Monitoring System. Summary of safety and effectiveness data. [FDA Web site]. 03/24/06. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf5/P050012b.pdf. Accessed April 5, 2017.

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Vigersky RA, Fonda SJ, Chellappa M, et al. Short- and long-term effects of real-time continuous glucose monitoring in patients with type 2 diabetes. Diabetes Care. 2012;35(1):32-8.

Voormolen DN, Devries JH, Franx A, et al. Effectiveness of continuous glucose monitoring during diabetic pregnancy (GlucoMOMS trial); a randomised controlled trial. BMC Pregnancy Childbirth. 2012;12(1):164.

Wei Q, Sun Z, Yang Y, et al. Effect of a CGMS and SMBG on maternal and neonatal outcomes in gestational diabetes mellitus: a randomized controlled trial. Sci Rep. 2016;6:19920.

Wilson DM, Beck RW, Tamborlane WV, et al. The accuracy of the FreeStyle Navigator continuous glucose monitoring system in children with type 1 diabetes. Diabetes Care. 2007;30(1):59-64.

Wojciechowski P, Rys P, Lipowska A, et al. Efficacy and safety comparison of continuous glucose monitoring and self-monitoring of blood glucose in type 1 diabetes. Pol Arch Med Wewn. 2011;121(10):333-43.

Wolpert HA. The nuts and bolts of achieving end points with real-time continuous glucose monitoring. Diabetes Care. 2008;31(Suppl 2):S146-S149.

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Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

THE FOLLOWING CODES ARE USED TO REPRESENT SHORT-TERM INTERSTITIAL CONTINUOUS GLUCOSE MONITORING:

95250, 95251


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A for a list of ICD-10 Diagnosis Codes for Short-term Interstitial Continuous Glucose Monitoring System.


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
Description: ICD-10 Diagnosis Codes for Short-term Interstitial Continuous Glucose Monitoring System




Policy History

Revisions from 05.00.24q
05/07/2018 This policy has been updated to remove the information regarding long-term continuous glucose monitoring (CGM) and add this information into the Insulin Pumps Policy # 05.00.79.

Revisions from 05.00.24p
01/01/2018This version of the policy will become effective 01/01/2018.

The following CPT code has been added to this policy: 95249
The following CPT codes have been revised, in this policy: 95250, 95251


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 05/07/2018
Version Issued Date: 05/07/2018
Version Reissued Date: N/A

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