Does Medi-Cal Cover CGM? How to Get Coverage

Continuous Glucose Monitors (CGMs) represent a notable advancement in managing diabetes. These devices continuously track glucose levels, providing real-time data that empowers individuals to make informed decisions about their diet, exercise, and medication. CGM use can lead to better diabetes management, reducing the frequency of fingerstick checks and providing a more comprehensive understanding of glucose trends.

Medi-Cal operates as California’s Medicaid program, offering essential healthcare services to eligible low-income individuals and families. This public health insurance program ensures access to medical care for those who might otherwise face financial barriers. Understanding Medi-Cal benefits, including coverage for advanced tools like CGMs, is important for beneficiaries seeking to manage chronic conditions.

Scope of Medi-Cal CGM Coverage

Medi-Cal provides coverage for Continuous Glucose Monitors, acknowledging their value in supporting diabetes care. This coverage is contingent upon a determination of “medical necessity,” meaning a healthcare provider must confirm the device is required for effective management of a patient’s condition. The expansion of CGM coverage under Medi-Cal has evolved, with significant updates broadening access.

As of January 1, 2022, Medi-Cal expanded its coverage to include CGMs for beneficiaries aged 21 and older who have type 1 diabetes. Prior to this policy change, CGM coverage was often more restricted. This adjustment aimed to address disparities in diabetes care access.

The coverage applies to both therapeutic and non-therapeutic CGM systems. These systems typically consist of a sensor, a transmitter, and a receiver or compatible smart device to display glucose data. Coverage typically requires prior authorization from Medi-Cal, ensuring specific medical criteria are met before the device and its supplies are approved for reimbursement.

Medi-Cal Rx, which manages pharmacy benefits, oversees CGM coverage. This means that CGMs and their associated supplies, such as sensors and transmitters, are processed through the pharmacy benefit. Quantity limits are in place for supplies; for instance, as of June 7, 2024, limits for CGM sensors transitioned from a 30-day and 90-day limitation to a quantity per day limitation, streamlining access.

Meeting the Specific Medical Criteria

To qualify for Medi-Cal CGM coverage, individuals must meet specific medical criteria that establish the necessity of the device for their diabetes management. A primary qualification involves a diagnosis of type 1 diabetes. Individuals with type 2 diabetes may also qualify if their condition is insulin-dependent, often requiring intensive insulin therapy such as multiple daily injections or insulin pump use.

A history of problematic hypoglycemia or frequent hyperglycemia is another eligibility factor. This includes documented recurrent Level 2 hypoglycemic events (glucose levels below 54 mg/dL) that persist despite attempts to adjust medications or treatment plans within the past year. Severe hypoglycemic events (needing assistance due to seizures or loss of consciousness) also contribute to qualifying criteria. Impaired awareness of hypoglycemia can also be a qualifying condition.

For individuals with gestational diabetes, CGM coverage may be approved for the duration of the pregnancy and up to 12 months postpartum. Comprehensive documentation from a healthcare provider is essential to support medical necessity. This includes detailed medical records, a current prescription for the CGM system, and a letter of medical necessity outlining how the device will benefit the patient.

Documentation must include a recent Hemoglobin A1c (HbA1c) value, which must typically be measured within eight months of the prior authorization request date. The prescription and supporting medical records must originate from a qualified healthcare professional with experience in diabetes management.

Qualified Healthcare Professionals

Endocrinologists
Primary care physicians (MDs or DOs)
Nurse practitioners
Clinical nurse specialists
Physician assistants
Certified nurse midwives

Navigating the Prior Authorization Process

Once medical criteria for CGM coverage have been met, the next step involves navigating the prior authorization process with Medi-Cal Rx. The healthcare provider is responsible for initiating this request on behalf of the patient. This process ensures the requested CGM system aligns with Medi-Cal’s coverage guidelines and medical necessity requirements.

The prior authorization request must include comprehensive information to support approval. This encompasses patient demographics, a summary of the patient’s medical history, the specific CGM device requested, and detailed justification for its medical necessity based on the established criteria. As of December 1, 2023, Medi-Cal Rx began accepting a single prior authorization request that covers all components of a CGM system (e.g., sensors, transmitters, and readers), simplifying what was previously a more fragmented process.

Providers have several methods for submitting prior authorization requests.

Prior Authorization Submission Methods

Utilizing the Medi-Cal Rx Secured Provider Portal
Submitting through the CoverMyMeds platform
Sending requests via fax
Mailing the necessary documentation

Prior authorization requests generally cannot be submitted over the phone, and patients cannot initiate these requests themselves. Upon submission, Medi-Cal Rx reviews the request. Initial and subsequent reauthorizations for CGMs are typically granted for one year, beginning from the date of approval. Once approved, patients are able to receive up to a 90-day supply of their CGM devices and supplies per fill.

If a prior authorization request is denied, providers have the option to appeal the decision. Appeals can be submitted via the Medi-Cal Rx provider portal, by fax, or through mail, and typically must be filed within 180 days of the initial denial. Medi-Cal Rx aims to make a decision on provider appeals within 60 days of receipt. Beneficiaries who wish to appeal a denial can request a State Fair Hearing through the California Department of Social Services. Once prior authorization is secured, the patient can obtain their CGM device and supplies, often through a participating pharmacy or durable medical equipment supplier.