Provider Alert! Therapeutic Continuous Glucose Monitors Become Benefit of Texas Medicaid

Attention: Primary Care Providers and Endocrinologists 

Effective Date: April 1, 2020

Call to action: Texas Children’s Health Plan (TCHP) supports Texas Medicaid Health Partnership’s (TMHP) decision to include therapeutic continuous glucose monitors (CGM) as a benefit for Texas Medicaid recipients.  A therapeutic CGM device requires prior authorization and is used as a replacement for self-blood glucose monitoring (SBGM).
Members who have Type I or Type II diabetes may be considered for therapeutic CGM. All of the following medical necessity criteria must be met.

• The member has been using a SBGM and performing frequent (at least four times per day) testing.
• Insulin injections are utilized three or more times per day or is on an insulin pump.
• The member’s insulin treatment regimen requires frequent adjustment due to SBGM or CGM testing results.
• The member is able, or has a caregiver who is able, to learn to use the device, hear and view CGM alerts and respond appropriately.
• A member with hypoglycemia unawareness or several episodes of hypoglycemia per day may also qualify for therapeutic CGM if the above criteria are not met.

How this impacts providers:

• The initial order from a provider who is managing the member’s diabetes is valid for a six (6) month period.
• If a member demonstrates compliance with the use of the CGM and treatment plan, an additional six (6) month order may be submitted.
• After the first year, an order for replacement sensors, transmitter, and receiver (following frequency rules) may be submitted for a twelve (12) month period.
• The therapeutic CGM device billing code is K0554 and limited to one device per three years.
• When a therapeutic CGM device is approved, the related supplies (procedure code K0553) are also covered at once per calendar month.

Next steps for providers: The provider notice is available on the TMHP website. Providers should ensure staff are aware of this guidance. The TCHP guideline for therapeutic Continuous Glucose Monitors (CGMs) is available here.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers