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Updated Prior Authorization Criteria for Diabetic Equipment and Supplies 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 criteria for diabetic equipment and supplies will change for Texas Medicaid.

Overview of Benefit Changes

Changes to this medical benefit include the following:

  • Insulin dependence is not required for continuous glucose monitor (CGM) eligibility when other criteria are met.
  • Updated general requirements for all items requiring prior authorization
  • Updated prior authorization criteria for CGMs

General Requirement for All Items

The make and model of a requested device will no longer be required on the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form but will be required on the DME Certification and Receipt Form.

Prior Authorization for CGMs

The following initial criteria must be met for the client to qualify for the CGM benefit:

  • A client must have diabetes mellitus and meet one of the following medical necessity criteria:
    • The client is insulin-treated.
    • The client has a history of problematic hypoglycemia with documentation of at least one of the following:
      • Recurrent (more than one) level 2 hypoglycemic events (glucose <54 mg/dL [3.0 mmol/L]) that persist despite multiple (more than one) attempts to adjust medications or modify the diabetes treatment plan
      • A history of one level 3 hypoglycemic event (glucose <54 mg/dL [3.0 mmol/L]) characterized by altered mental or physical state requiring third-party assistance for the treatment of hypoglycemia
  • A client with unawareness of hypoglycemia or several episodes of hypoglycemia a day also qualifies for the CGM benefit if the client does not meet the criteria outlined above.
  • The client’s treating practitioner has concluded that the client or the client’s caregiver has sufficient training using the CGM prescribed, as evidenced by providing a prescription for the appropriate supplies and frequency of blood glucose testing.
  • The CGM is prescribed in accordance with its U.S. Food and Drug Administration (FDA) indications for use.

Within six months prior to ordering the CGM, the treating practitioner must have an in-person or Medicaid-approved telehealth visit with the client to evaluate their diabetes control and determine that the criteria above are met.

For continued CGM coverage, the treating practitioner must have an in-person or Medicaid-approved telehealth visit with the client every six months following the initial prescription of the CGM to document adherence to the CGM regimen and diabetes treatment plan.

Prior authorization is not required for CGM supplies once a device is approved. When a CGM (procedure code E2102 or E2103) is covered, the related supply allowance (procedure code A4238 or A4239) is also covered.

There are no devices on the United States market that function as stand-alone adjunctive CGM devices according to the Centers for Medicare & Medicaid Services (CMS) definition of durable medical equipment (DME). Current technology for adjunctive CGM devices (procedure code E2102) operates in conjunction with an insulin pump, and its supplies (procedure code A4238) are covered when the beneficiary meets both the CGM coverage criteria and the coverage criteria for an external insulin infusion pump.

Smart devices (smart phones, tablets, personal computers, etc.) used as CGM monitors are not a benefit of Texas Medicaid.

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