Continuous Glucose Monitoring (CGM) is a technology that uses a small sensor inserted under the skin to measure glucose concentrations and send data wirelessly. This allows individuals with diabetes to track their levels throughout the day and night without frequent fingerstick checks. The Department of Veterans Affairs (VA) recognizes the clinical benefit of this technology and provides coverage for eligible veterans.
VA Coverage Criteria and Eligibility
Access to a Continuous Glucose Monitor through the VA is determined by specific clinical guidelines outlined in Veterans Health Administration (VHA) policy. The primary requirement is a diagnosis of diabetes and treatment with daily insulin to achieve target glycemic management or avoid hypoglycemia. This includes veterans with Type 1 diabetes and those with Type 2 diabetes on an intensive insulin regimen.
The VA criteria recommend considering a CGM for veterans who require daily insulin and have an increased risk of hypoglycemia, or those unable to reach their glucose goals despite adherence to therapy. Necessity may also stem from an inability to perform frequent fingerstick checks due to a disability or disease. Additionally, veterans whose job activities would put them at risk during a hypoglycemic event may qualify for coverage.
Beyond the clinical need, the veteran must demonstrate the skills and knowledge to effectively use the device. This includes understanding the data provided by the CGM and knowing when to perform a confirmatory fingerstick check. The veteran must also agree to maintain regular medical appointments with the diabetes management team, typically at least every six months, for continued assessment and support.
The VA Prescription and Approval Process
The procedural steps for obtaining a CGM begin with a consultation with a VA healthcare provider, such as a Primary Care Provider, an Endocrinologist, or a member of the specialized Diabetes Management Team. During this appointment, the provider assesses the veteran against the VHA’s clinical criteria and documents the medical justification for the device. This confirms the veteran’s need, ability to use the technology, and the plan for follow-up care.
Once the clinical need is established, the provider initiates an order for the CGM. Historically, these devices were processed through the Durable Medical Equipment (DME) channel, which often resulted in significant delays. The VA has streamlined this process by utilizing the national pharmacy benefit for the entire CGM system. This shift has substantially improved access, allowing veterans to receive their initial transmitter and sensors quickly.
The approval process requires the provider to reference a formal progress note justifying the device and outlining the patient’s commitment to follow-up care. Before the prescription is finalized, the veteran will receive mandatory education and training on the device’s proper use. This ensures the veteran can successfully integrate the CGM into their daily diabetes management routine and interpret the data accurately.
Covered Devices and Supplies Management
The VA provides coverage for Continuous Glucose Monitors through national contracts, meaning access is limited to specific, preferred brands on the VA formulary. The formulary typically includes both real-time and intermittently scanned CGM systems from major manufacturers. The choice of device depends on the veteran’s clinical needs, the provider’s recommendation, and the current national contract.
The logistical management of ongoing supplies has been simplified. Most veterans obtain replacement sensors and transmitters directly through the VA pharmacy benefit. This allows for quick and regular refills, often via mail-order services, eliminating the need to navigate the slower DME process for recurring supplies. Sensors are typically replaced on a schedule determined by the device’s lifespan, usually every 10 to 14 days.
For veterans whose diabetes or related conditions are service-connected, the CGM system and its necessary supplies are provided at no cost. Even for non-service-connected conditions, many veterans enrolled in VA healthcare experience minimal or no co-payments for their diabetes supplies, including the CGM.