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Texas Medicaid Prior Authorization Updates for Diabetic Equipment and Supplies

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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 November 1, 2025, Texas Medicaid will update prior authorization criteria for diabetic equipment and supplies.

Note: Daily blood glucose logs are not required for prior authorization requests for external insulin pumps or continuous glucose monitors (CGMs).

Prior Authorization for Rental of External Insulin Pumps

To meet prior authorization criteria for rental of external insulin pumps, clients diagnosed with type 1 or type 2 diabetes must:

  • Receive multiple daily administrations of insulin.
  • Meet at least two of the following criteria:
    • Elevated glycosylated hemoglobin level (HbA1c) over 7.0 percent
    • History of dawn phenomenon or Somogyi phenomenon with fasting blood sugars frequently exceeding 200 mg/dl
    • History of severe glycemic excursions with wide fluctuations in blood glucose
    • History of problematic hypoglycemia (less than 60 mg/dL) with or without hypoglycemic unawareness
    • Anticipation of pregnancy within three months

Refer to the current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.12.5.1, “Prior Authorization,” for additional prior authorization criteria.

Prior Authorization for CGMs

For initial prior authorization of a CGM, the treating practitioner must have an in-person or Medicaid-approved telemedicine visit with the client within six months before ordering a monitor to:

  • Evaluate the client’s diabetes control.
  • Determine that the client meets the prior authorization criteria for a CGM.

Refer to the current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.12.7.1, “Prior Authorization,” for prior authorization criteria.

Continued Coverage Requirements

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

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