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Prior Authorization Language to Change for Continuous Glucose Monitoring Procedure Codes 95250 and 95251 Effective February 1, 2024

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after February 1, 2024, the prior authorization language will change for continuous glucose monitoring (CGM) procedure codes 95250 and 95251.

This language update will align with the American Diabetes Association (ADA) Standards for Medical Care 2023 and the American Association of Clinical Endocrinology (AACE) 2021 Clinical Practice Guideline on the Use of Advanced Technology in the Management of Persons with Diabetes Mellitus.

This update will include the following:

  • Clients who are diabetic but are not on insulin will now be eligible for CGM.
  • Clients will no longer be required to take a minimum number of blood glucose measurements per day.

CGM may be prior authorized for clients with diabetes mellitus. The CGM must be prescribed by the client’s treating practitioner that performs glucose monitoring.

The client must be compliant with their medical regime, receive daily insulin administrations or meet the criteria for non-insulin dependent diabetics, or use an insulin pump and perform documented daily self-monitoring of blood glucose.

For all diabetic clients who are not using insulin, at least one or more of the following conditions must be present:

  • Frequent unexplained hypoglycemic episodes
  • Unexplained large fluctuations in daily, pre-prandial blood glucose
  • Episodes of ketoacidosis or hospitalization for uncontrolled glucose

For more information, call the TMHP Contact Center at 800-925-9126.