A Continuous Glucose Monitor (CGM) is a medical device that measures glucose levels throughout the day and night. Unlike traditional fingerstick testing, which offers a single snapshot, a CGM uses a tiny sensor inserted just under the skin to measure glucose in the interstitial fluid every few minutes. This real-time data is sent wirelessly to a receiver or smartphone app, showing current levels, trends, and direction of change. Obtaining this technology involves a multi-step process that starts with a medical evaluation to confirm eligibility and secure a formal prescription. This guide outlines the necessary steps to successfully order your CGM system.
Determining Medical Eligibility
The first step in obtaining a CGM involves confirming that your medical history meets the clinical guidelines set by healthcare providers and payers. A diagnosis of diabetes mellitus is the starting point for coverage criteria. Most insurance plans require the patient to be treated with insulin, either through multiple daily injections or the use of an insulin pump.
Coverage is also extended to individuals with a documented history of problematic hypoglycemia, defined as recurrent low glucose events despite medication adjustments. Problematic hypoglycemia often means having multiple Level 2 events (glucose below 54 mg/dL) or a single Level 3 event requiring assistance. The healthcare provider must document this medical necessity clearly within the patient’s chart notes.
Eligibility requires a recent visit with your treating clinician, typically within six months of ordering the device. This visit evaluates your current diabetes control and confirms you meet the necessary criteria. Ongoing approval for supplies depends on continued use and regular follow-up visits to ensure the device improves glycemic management.
Securing the Necessary Prescription
Once medical eligibility is confirmed, your healthcare provider (HCP) must generate a detailed prescription. The order must be specific, naming the exact CGM system, including the sensor type, replacement frequency, and transmitter details. For example, the prescription must specify the sensor life (e.g., 10-day or 14-day) and the quantity needed for a specific supply period, such as a 90-day refill.
The prescription often serves as evidence that the patient has received adequate training on the proper use of the CGM system. Your HCP must ensure the electronic health record justifies the need, citing the specific clinical criteria you meet. This documentation forms the basis for the insurance company’s decision on coverage and prior authorization. Without these precise details, the prescription may be rejected by the dispensing supplier or payer.
Navigating Insurance Coverage and Costs
Determining how your insurance plan covers the CGM is essential, as it can fall under either pharmacy benefits or Durable Medical Equipment (DME) benefits. Pharmacy coverage is simpler, often handled like a regular prescription with a predictable copay. However, many insurers classify CGMs as DME, which subjects the order to stricter rules and often requires a formal Prior Authorization (PA) process.
Prior Authorization is a request from your doctor to the insurance company, demonstrating the medical necessity of the CGM before coverage is approved. This step is mandatory, particularly for patients with Type 2 diabetes not on intensive insulin or those relying on the problematic hypoglycemia criteria. The PA process can take several weeks and requires the submission of detailed patient records and lab results.
If the initial request is denied, you have the right to appeal the decision by working with your provider’s office to submit additional documentation. Investigate the cost structure under both benefit types; a DME supplier might require meeting a high deductible, while a pharmacy benefit may only require a set copay. Many CGM manufacturers offer patient assistance programs or discount cards that can lower out-of-pocket expenses.
Finalizing the Order and Selecting a Supplier
After receiving confirmation that your prescription is authorized and covered, the final step is choosing the supplier to fulfill the order. You will choose between a local retail pharmacy or a specialized Durable Medical Equipment (DME) supplier. A retail pharmacy often provides the quickest turnaround time, allowing immediate pickup once the prescription clears.
A specialized DME supplier may be required by your insurance plan, especially for Medicare or certain commercial plans. This route may involve longer lead times for the initial order, sometimes taking a week or more. However, these suppliers offer comprehensive education and support for the device, which can lead to higher patient adherence rates. Coordinate with the chosen supplier and your physician to establish an automatic refill schedule for sensors and transmitters, ensuring uninterrupted access to your continuous glucose data.