Certificate of medical necessity cgm
Medicaid in Colorado has certain eligibility requirements that must be met in order to provide coverage for personal CGM. If the patient does not meet them, Professional CGM may be an option for intermittent use. This resource will help you navigate Colorado Medicaid’s eligibility requirements for coverage, ordering and insurance authorization, and documentation. To download this resource as a PDF, click here.
For a comparison guide on helping your patient choose a CGM and tips on navigating common problems, click here.
Colorado Medicaid Eligibility Requirements for personal CGM
In order to be eligible for Colorado Medicaid coverage of personal CGM, the following requirements must be met:
- The patient self-monitors glucose at least 3 times daily (e.g. fingerstick blood sugars);
- The patient is treated with 3 or more daily administrations of insulin or administers insulin continuously via pump;
- The patient requires frequent adjustment to the insulin treatment regimen based on glucose results (either finger stick or CGM readings)
- The patient has had or will have education specific to the therapeutic CGM system being requested
- The patient and/or their caregiver can hear and view CGM alerts;
- The patient has been seen for diabetes management in past 6 months and will continue to be seen every 6 months for this purpose;
- The patient meets the CGM manufacturer’s recommendations for age range, monitoring and calibration requirements (if applicable), or has otherwise qualifying circumstances that make therapeutic CGM medically necessary.
- For continuing eligibility, all of the above must be met and Colorado Medicaid requires recertification every 6 months; be sure to schedule diabetes follow up for within 6 months of the last visit.
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Example Documentation
Chart note example: The following is an example of text that you can add to your chart notes for patients meeting Colorado Medicaid’s eligibility criteria. You can copy/paste, add to your EHR’s macro library (sometimes called smartphrases, dotphrases, or auto-text), and/or modify as needed:
- This patient has a diagnosis of diabetes; self-monitors glucose at least 3 times daily; is treated with 3 or more daily administrations of insulin or continuous insulin infusion via pump; requires frequent adjustment of the insulin treatment regimen based on glucose results; has received or will receive education specific to the CGM system being prescribed; is able themselves or has a caregiver who is able to hear and view CGM alerts and respond accordingly; has been personally seen to evaluate their diabetes treatment within the past 6 months; meets the manufacturer’s recommendations for age range, monitoring and calibration requirements or otherwise has circumstances that make continuous glucose monitoring medically necessary.
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How to Order a Dexcom
- Complete the Byers CGM Order Form (available as a printable form or fillable form ), the Acentus Standard Written Order Form ( available here ), or the ADS (US Med) Order Form
- Email or Fax: chart notes, Order Form, and patient contact information (phone, address) to one of the following DME companies:
Byers Pharmacy
568 US Highway 36
Byers, CO 80103-9700
Store number: 109676
Phone: 303-822-9371
Fax: 1-833-479-0707
Email: dme@byerspharmacy.com
Acentus
Local Contact: Kelsey Botkin – Diabetes CGM – Account Manager
Phone: 763-688-1241 or 866-684-2507
Fax: 866-695-2183
Email: kelseyb@acentus365.com
ADS (US Med)
Local Contact: Madison Morton- Colorado
Phone: (720) 551-7672
Fax: 1-760-444-8771
Email: mmorton@usmed.com
CCS Medical
Local Contact: Lori Lefevre
Phone: 720-836-0574
Fax: 888-235-5598
Email: lori.lefevre@ccsmed.com
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How to Order a Freestyle Libre
- Complete the Libre Certificate of Medical Necessity (or the Byers CGM Order Form, Acentus Standard Written Order or ADS (US Med) Order Form)
- To order a Freestyle Libre if patient has a compatible smartphone: Freestyle Libre 2 or 3 Sensors – change sensor every 14 days, dispense 2 sensors (28-day supply), 11 refills; Freestyle Libre 2 plus – change sensor every 15 days, dispense 2 sensors (30-day supply), 11 refills
- If patient does not have a compatible smartphone then also order: Freestyle Libre 2 or 3 Reader - dispense 1 reader (reader life is approx. 3 years)
- Send the Libre Certificate of Medical Necessity, chart notes, and prescription to one of the following DME companies:
Byers Pharmacy
568 US Highway 36
Byers, CO 80103-9700
Store number: 109676
Phone: 303-822-9371
Fax: 1-833-479-0707
Email: dme@byerspharmacy.com
ADS-United States Medical Supply
Phone: 877-270-6508
Fax: 866-347-8544
Email: abbott@usmed.com
Local Contact: Madison Morton - CGM/Pump Territory Business Manager
Email: mmorton@usmed.com
Phone: 720-551-7672
Fax: 305-722-9505
Acentus
Local Contact: Kelsey Botkin – Diabetes CGM – Account Manager
Phone: 763-688-1241 or 866-684-2507
Fax: 866-695-2183
Email: kelseyb@acentus365.com
CCS Medical
Local Contact: Lori Lefevre
Phone: 720-836-0574
Fax: 888-235-5598
Email: lori.lefevre@ccsmed.com
If patients have Rocky Mountain Health/Prime then send to:
Byram
Local Contact: Nicholas Bohen- Account Manager
Phone: 801-716-8744
Email: nbohen@byramhealthcare.com
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How to Order a Medtronic CGM
- For Medtronic, visit their healthcare professional website for their most current resources: https://www.medtronic.com/us-en/healthcare-professionals/products/diabetes/continuous-glucose-monitoring-systems.html
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Eversense
- Eversense requires that the transmitter be implanted; it is recommended that you seek preauthorization for the implantation procedure before ordering. To become an Eversense provider and to pursue information on ordering, visit https://www.ascensiadiabetes.com/eversense/become-a-provider/#get-started-form .
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Additional Help
Dexcom:
Aaron West - Territory Business Manager
Email: aaron.west@dexcom.com
Can help with most Dexcom items, including Hello Dexcom samples.
Terra Thompson, RN, CDE - Clinical Account Manager
Email: terra.thompson@dexcom.com
Can help with all training and Clarity.
Kevin Stroud - District Business Manager
Email: Kstroud@dexcom.com
Can assist with urgent items.
Abbott Freestyle Libre:
Neil Henson– Diabetes Sales Specialist
Phone: 303-513-4307
Email:neil.henson@abbott.com
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Alternatives if CGM is not Covered by Medicaid
- Professional CGM
- Sample of Personal CGM
- Self-pay for Personal CGM, with or without various coupons, copay reduction programs, and/or vouchers
- If they haven’t been seen for diabetes management in the past 6 months, have them seen for this purpose (in-person or via telehealth).
- Membership warehouses with pharmacies, like Costco and Sam’s Club, often offer the lowest prices, are usually open to non-members, and may have additional significant discounts for members.
