317:30-5-211.25. Continuous glucose monitoring
(a) Continuous glucose monitoring (CGM). CGM means a minimally invasive system that measures glucose levels in subcutaneous or interstitial fluid. CGM provides blood glucose levels and can help members make more informed management decisions throughout the day.
(b) Medical necessity. CGM must be determined by a provider to be medically necessary and documented in the member's plan of care as medically necessary and used for medical purposes. A request by a qualified provider for CGM in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity. CGM devices must be approved by the U.S. Food and Drug Administration (FDA) as non-adjunctive and must be used for therapeutic purposes. Devices may only be used for members within the age range for which the devices have been FDA approved.
(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2). Requests for CGM must include all of the following documentation:
(1) Prescription by a qualified provider;
(2) Member diagnosis that correlates to the use of CGM;
(3) Documentation of the member testing to include the frequency each day;
(4) Documentation member is insulin-treated to include frequency of daily or is using insulin pump therapy;
(5) Documentation member's insulin treatment regimen requires frequent adjustment;
(6) The member and/or family member has participated in age appropriate diabetes education, training, and support prior to beginning CGM; and
(7) In-person or telehealth visit [within the last six (6) months] between the treating provider, member and/or family to evaluate their diabetes control.
(8) For full guidelines please refer to www.okhca.org/mau.