Provider FAQ for 2022 Member Benefits and Services

Provider Talking Points for Reason Codes on Remittance Advice

Provider Claims FAQ

What are the CGM coverage requirements under Medicare?

CGMs are covered for members who:

• Have been diagnosed with diabetes mellitus; AND
• Administer insulin at least 3 times per day or use a continuous insulin pump; AND
• Adjust insulin doses frequently based on the testing results; AND
• Have had a visit within the last six (6) months with his or her prescriber

All coverage requests should be submitted through the member’s medical group.  For Medicare coverage policies, please see Local Coverage Determination (LCD): Glucose Monitors (L33822) and Local Coverage Article: Glucose Monitor - Policy Article (A52464).

What are the differences between non-adjunctive vs. adjunctive CGMs?

Non-adjunctive CGMs can be used as a complete replacement for traditional fingerstick blood glucose testing supplies and do not require a separate blood glucose monitor (BGM) to confirm testing results.

Adjunctive CGMs must be used in conjunction with standard finger stick tests using a home BGM to confirm testing results.

Both non-adjunctive and adjunctive CGMs are considered DME.

Why is my patient’s CGM rejecting/not covered at the pharmacy?

CGM supplies are covered under the durable medical equipment (DME) benefit under Medicare. For SCAN members, DME supplies are provided by the medical group’s contracted DME supplier and are not coverable under the pharmacy benefit.

My patient previously received a fill at the pharmacy, why is their CGM refill now rejecting?

Your patient may have received a temporary fill during their first 90 days of enrollment with SCAN at the pharmacy. Known as a transition fill, this allows patients to have access to these CGM supplies while they are new to the plan. This transition fill also allows you time to request authorization (referral) from the medical group to cover and supply CGMs under the DME benefit.

Why are CGMs covered under the DME benefit and not the pharmacy benefit (Part D)?

Medicare covers CGMs under the DME benefit. For SCAN members, this benefit is managed by the medical group and will not be covered at the pharmacy. Please make sure you DO NOT send an authorization request to Express Scripts. They only manage pharmacy authorizations and will not process your request.

What are the next steps to ensure my patient receives their CGMs in a timely manner?

Submit an authorization to your patient’s medical group with the appropriate CGM DME supply codes to ensure the CGM gets covered. 

1. Documentation showing that your patient meets the criteria to use CGM supplies.
2. Prescription for CGM supplies (refer to HCPCS and ICD-10 codes listed above).
3. Documentation showing that your patient’s diabetes diagnosis will be re-evaluated and managed every 6 months.