Skip to main content

TMPPM Update for Continuous Glucose Monitoring Effective November 1, 2025

Last updated on

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.

On November 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) will update prior authorization language in the Texas Medicaid Provider Procedures Manual (TMPPM), Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, section 9.2.24, “Continuous Glucose Monitoring (CGM).”

The updated prior authorization language will include the following:

  • The client must be compliant with their medical regime, perform multiple daily insulin administrations, or use an insulin pump.
  • The provider must document the medical necessity of CGM for the client.
  • The client’s medical record must include a provider statement confirming a history of daily self-blood glucose monitoring.

Prior Authorization Criteria

Texas Medicaid will consider approving prior authorization requests for diabetic clients who are not using insulin if at least one of the following conditions is present:

  • Frequent problematic hypoglycemic episodes
  • Unexplained large fluctuations in daily, preprandial blood glucose
  • Episodes of ketoacidosis or hospitalization for uncontrolled glucose

Note: Daily blood glucose logs are not required for prior authorization requests.

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