How Do I Get My Insurance to Cover a Continuous Glucose Monitor When I Have Type 1 Diabetes?

By Sina Hartung, MMSC-BMI, Harvard Medical SchoolReviewed by Eureka Health Medical Group
Published: June 19, 2025Updated: June 19, 2025

Summary

Most U.S. insurers approve a real-time CGM for people with documented type 1 diabetes if you: 1) take multiple daily insulin doses or use an insulin pump, 2) provide glucose logs showing you test at least four times a day, and 3) submit a clinician’s prescription and recent clinical note. Medicaid and some commercial plans also require A1C results and proof of diabetes education. Meeting these criteria and using the right billing codes usually secures coverage within 14–30 days.

Do insurers automatically approve CGMs for everyone with type 1 diabetes?

No. Even with a type 1 diabetes diagnosis, most plans demand proof that a CGM is medically necessary and that basic criteria are met.

  • Multiple daily insulin doses are a mustVirtually all commercial plans and Medicare require documentation that you take at least three insulin injections per day or use a pump.
  • Four-times-daily finger-stick logs still matterInsurers often want 14–30 days of meter readings to show you actively manage glucose. A clinic print-out or device download works.
  • A valid prescription must cite ICD-10 E10.9Claims without the specific type 1 code are routinely denied.
  • Recent progress note is the top attachment errorDenials frequently stem from missing or outdated visit notes—even if everything else is correct.
  • Two diabetes visits within 6 months are built into some policiesKaiser Permanente’s adult review criteria require at least two in-person or video appointments with a provider in the six months preceding a CGM request. (KP)
  • Patient training and engagement are part of the approval checklistAnthem’s CG-DME-42 policy only approves CGM when the user or caregiver demonstrates understanding of the technology and commitment to integrate it into a comprehensive diabetes plan. (Anthem)

References

Which insurance red flags can delay or deny CGM approval?

Several predictable pitfalls stall coverage. Spot them early to avoid months of appeals.

  • Incorrect HCPCS code triggers instant rejectionMedicare and most private payers accept code K0554 for a CGM receiver plus sensors; using miscellaneous code E1399 is a common mistake.
  • Gaps in blood-glucose log dates raise doubtsIf your self-monitoring record shows fewer than four checks on over 20 % of days, reviewers often label the request "not medically necessary."
  • A1C under 6.5 % without hypoglycemia history looks "well controlled"Plans may question why a CGM is needed if they don’t see hypo documentation in the note.
  • Out-of-network supplier bills are flaggedSelecting a durable-medical-equipment vendor outside your plan’s network inflates costs and increases scrutiny.
  • Incomplete prior-authorization form stalls the clock"More than 40 % of CGM denials we review stem from missing fields on the PA form," notes the team at Eureka Health.
  • Pharmacy-benefit submission for a DME-only device guarantees denialMany commercial plans list CGMs under durable medical equipment; Beyond Type 1 warns that filing under the pharmacy benefit “will automatically be denied until re-routed through the DME channel.” (BT1)
  • Medicare still insists on proof of ≥4 finger-stick tests per day before CGM approvalA 2019 review notes that CMS policy requires documentation of at least four self-monitoring blood-glucose checks daily in the 30 days preceding the order, a hurdle that disqualifies many applicants who test less frequently. (NIH)

References

How do policy rules differ between Medicare, Medicaid, and commercial plans?

Each payer category enforces its own CGM checklist—knowing the nuances saves time.

  • Medicare now covers all types of insulin therapySince April 2023, you no longer need strict four-per-day finger-sticks to qualify, but you must attest to "frequent adjustment" of insulin.
  • State Medicaid programs cap sensor quantityExample: Texas limits to 60 sensors per 180 days unless a physician writes a medical exception.
  • Employer plans often add diabetes-education proofCarriers may want a certificate from an ADA-recognized program within the last 12 months.
  • Marketplace bronze plans may impose higher DME cost-shareExpect 30–50 % coinsurance even after approval, so compare formulary tiers.
  • COBRA keeps prior authorization but resets deductiblesSwitching to COBRA preserves medical necessity paperwork but financial thresholds restart January 1.
  • 45 states and D.C. publish fee-for-service Medicaid CGM policiesAs of May 2023, only five states lack any written Medicaid fee-for-service CGM coverage, highlighting wide but uneven adoption. (CHCS)
  • Medicare Part B typically leaves a 20 % coinsurance for CGM usersEven after meeting the annual Part B deductible, beneficiaries usually pay one-fifth of the allowed CGM cost unless they have secondary coverage. (Diatribe)

References

What documents can I prepare myself to speed CGM authorization?

Getting paperwork right the first time cuts denial risk in half.

  • 14-day finger-stick log on one PDFUse your meter’s export tool; insurers prefer a single file rather than daily photos.
  • Most recent A1C lab as separate attachmentAttach the full lab report; summary numbers copied into notes are often rejected.
  • Clinic note with precise wordingAsk your clinician to include phrases like "Type 1 diabetes since age 14; patient meets criteria for CGM under policy XYZ."
  • Completed PA form with correct codesInclude ICD-10 E10.9, HCPCS K0554, and relevant NDCs for sensors; "If one code is off, start-over is inevitable," cautions Sina Hartung, MMSC-BMI.
  • Letter of Medical Necessity template readyHaving a pre-filled template reduces clinician workload and speeds signing.
  • Include insulin regimen proving ≥3 daily injectionsAnthem’s CGM policy requires documentation that the patient “requires multiple daily insulin injections or uses an insulin pump”; listing your exact dosing schedule in the chart note lets reviewers confirm this criterion instantly. (Anthem)
  • Attach highlighted copy of your plan’s CGM criteriaJDRF recommends pulling the insurer’s CGM policy or formulary before submitting a PA and sending the relevant pages with the request so the reviewer can verify compliance without extra follow-up. (JDRF)

References

Which labs, prescriptions, and follow-up visits do insurers ask for?

Besides a diagnosis, plans often require specific clinical data points.

  • A1C within the last 6 monthsMany payers reject results older than 180 days, even if they show poor control.
  • Serum C-peptide rarely required but keep it handyOnly some plans request C-peptide to confirm type 1 status, but having it available prevents surprise delays.
  • Insulin prescription linked to DME orderThe date on the insulin Rx should not predate the CGM order by more than 30 days to show active management.
  • Follow-up visit scheduled within 90 days"Insurers monitor adherence; scheduling a post-start visit demonstrates commitment," says the team at Eureka Health.
  • Fingerstick log documenting at least three daily checksCU Anschutz notes that some commercial plans still require evidence of self-monitoring blood glucose (SMBG) three or more times per day—often via a meter download or handwritten log—before authorizing CGM. (CUAnschutz)
  • Current HbA1c above target strengthens medical-necessity caseAnthem’s CG-DME-42 policy lists "inadequate glycemic control (HbA1c above target)" among the conditions that make CGM medically necessary, so including a recent elevated result can expedite approval. (Anthem)

References

How can Eureka’s AI doctor help gather everything insurers want?

Eureka’s app streamlines the evidence insurers demand, cutting manual effort.

  • Auto-generates a Letter of Medical NecessityInput your insulin regimen and glucose trends; the AI compiles text your clinician can sign in minutes.
  • One-click export of glucose logsPair your glucometer or existing CGM and the app bundles the last 30 days into an insurer-friendly PDF.
  • Pre-checks PA forms for missing fieldsA rules engine flags blank ICD-10 or HCPCS codes before you fax or upload.
  • Built-in chat with certified diabetes educators“We translate plan jargon into plain language so patients know exactly which document is still missing,” explains Sina Hartung, MMSC-BMI.

Why keep using Eureka after your CGM is approved?

Long-term support prevents lapses in coverage and optimizes care.

  • Tracks sensor refill windows automaticallyUsers receive alerts 10 days before sensors run out, preventing costly gaps in data.
  • A1C trend dashboard improves clinic visitsWomen using Eureka for diabetes care rate the lab tracker 4.8 out of 5 for clarity.
  • Private symptom journal helps detect patternsOnly you and your clinical team see the data; no advertising access.
  • Request prescription renewals inside the appIf your sensor script expires, Eureka forwards renewal details for clinician review under HIPAA-compliant encryption.
  • Evidence-based nudges reduce hypoglycemia eventsAfter three lows under 55 mg/dL in a week, the AI suggests basal rate review and prompts you to contact your endocrinologist.

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Frequently Asked Questions

I test my blood sugar four times daily but only take two insulin shots—will I qualify?

Probably not. Most insurers require at least three injections or an insulin pump for CGM approval.

Can my pediatric endocrinologist prescribe a CGM if I’m 17?

Yes, but some commercial plans require prior authorization from a board-certified pediatric endocrinologist for minors.

My latest A1C is 6.2 %. Could that cause a denial?

It can if your records lack documented hypoglycemia. Ensure your clinician notes any lows or glucose variability.

Do I need a separate prescription for sensors and transmitters?

Most suppliers create two linked prescriptions—one for the receiver and one for disposable sensors—using HCPCS K0554.

What if my insurer labels the CGM ‘convenience’ instead of ‘medical necessity’?

File an appeal with supporting glucose logs, hypoglycemia reports, and a detailed Letter of Medical Necessity from your endocrinologist.

Will switching from private insurance to Medicare disrupt coverage?

You’ll need a new prior authorization under Medicare rules, but prior documentation helps. Plan for a 30-day transition window.

How much will I pay out of pocket once approved?

Costs vary. Medicare Part B covers 80 % after deductible; many commercial plans charge 10–30 % coinsurance on durable medical equipment.

Can Eureka submit prior-authorization forms directly to my insurer?

Yes. Once your clinician signs, Eureka’s integrated fax gateway can send the complete package to most major payers.

Is my data safe when I connect my glucometer to the Eureka app?

Eureka encrypts data in transit and at rest and is HIPAA-compliant. Only you choose who sees your records.

This content is for informational purposes only and is not intended as medical advice. Always consult with a qualified healthcare provider for diagnosis, treatment, and personalized medical recommendations.

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