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Continuous Glucose Monitoring

Long-term continuous glucose monitoring (CGM) device monitoring of glucose levels in interstitial fluid, as a technique of diabetic monitoring, may be considered medically necessary when the following situations occur, despite use of best practices:
patients with type 1 diabetes who have demonstrated an understanding of the technology, are motivated to use the device correctly and consistently, are expected to adhere to a comprehensive diabetes treatment plan supervised by a qualified provider, and are capable of using the device to recognize alerts and alarms; or

patients with type 1 diabetes who have recurrent, unexplained, severe (generally blood glucose levels <50 mg/dL) hypoglycemia or impaired awareness of hypoglycemia that puts the patient or others at risk; or patients with poorly controlled type 1 diabetes who are pregnant. Poorly controlled type 1 diabetes includes unexplained hypoglycemic episodes, hypoglycemic unawareness, suspected postprandial hyperglycemia, and recurrent diabetic ketoacidosis. Short-term CGM monitoring of glucose levels in interstitial fluid may be considered medically necessary in patients with type 1 diabetes whose diabetes is poorly controlled, despite current use of best practices (see Policy Guidelines section). Poorly controlled type 1 diabetes includes the following clinical situations: unexplained hypoglycemic episodes, hypoglycemic unawareness, suspected postprandial hyperglycemia, and recurrent diabetic ketoacidosis. Short-term CGM monitoring of glucose levels in interstitial fluid may also be considered medically necessary in patients with type 1 diabetes prior to insulin pump initiation to determine basal insulin levels. Long-term CGM monitoring of glucose levels in interstitial fluid may be considered medically necessary in patients with type 2 diabetes who are willing and able to use the device and have adequate medical supervision and who experience significant hypoglycemia on multiple daily doses of insulin or an insulin pump in the setting of insulin deficiency. Short-term CGM monitoring of glucose levels in interstitial fluid may be considered medically necessary in patients with type 2 diabetes who require multiple daily doses of insulin whose diabetes is poorly controlled, despite current use of best practices (see Policy Guidelines section). Poorly controlled type 2 diabetes includes the following clinical situations: unexplained hypoglycemic episodes, hypoglycemic unawareness, and persistent hyperglycemia and A1C levels above target. Short-term CGM monitoring of glucose levels in interstitial fluid may be considered medically necessary in patients with type 2 diabetes who require multiple daily doses of insulin to determine basal insulin levels prior to insulin pump initiation. Other uses of long-term and short-term CGM monitoring of glucose levels in interstitial fluid as a technique of diabetic monitoring including use in gestational diabetes are considered investigational. The use of intermittently scanned (flash) CGM devices is considered investigational. The use of implantable CGM devices is considered investigational.

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