TRICARE coverage of Continuous Glucose Monitoring Systems (CGMS)
July 9, 2020
On January 1, 2020, TRICARE revised its CGMS benefit to allow beneficiaries with uncontrolled diabetes the use of FDA-approved CGMS.
TRICARE coverage includes both therapeutic and non-therapeutic devices.
Therapeutic CGMS is defined as a device that is approved by the FDA for non-adjunctive use (i.e., used as a replacement for finger stick BGM testing). Therapeutic (non-adjunctive) CGMS and supplies shall be reported utilizing HCPCS codes K0553-K0554 (or subsequent codes if replaced or renumbered). Devices that are labeled for use as therapeutic (non-adjunctive), even if the patient continues to perform glucose self-testing (e.g., finger sticks), shall be reported utilizing these codes.
Non-therapeutic CGMS is defined as a device that is approved by the FDA for use to complement, not replace, information obtained from finger stick testing. Adjunctive (non-therapeutic) CGMS and supplies should be reported with A9276 - A9278 (or subsequent codes if replaced or renumbered), with providers reminded of the requirement to use the most appropriate code for the service rendered. Only those devices which are not labeled by the FDA for therapeutic use (i.e., adjunctive, or only labeled to complement but not replace standard blood glucose monitoring) may be reported utilizing these codes.
Specific criteria must be met for coverage, as outlined in TPM Chapter 8, Section 5.3. A benefit review determination is available and encouraged for the initial system.
