Continuous Glucose Monitoring Stakeholder Engagement Questions and Answers
This webpage summarizes:
Unanswered stakeholder questions received during the stakeholder engagement session held by the Department of Health Care Policy and Financing (HCPF) on May 7, 2025 regarding expansion of Continuous Glucose Monitor (CGM) medical device reimbursement options.
Below each item, HCPF has provided an interim response.
Important Note: There are several stages of policy development and implementation. Any responses on this webpage represent a snapshot of HCPF’s position as of June 26, 2025 and should not be read as final policy determination.
Where can I find policy changes and updates shared in the stakeholder meeting, held on May 7, 2025?
The May 7, 2025 meeting presentation and recording are posted on the Continuous Glucose Monitoring (CGM) Stakeholder Engagement webpage.
What is the proposed effective date for the changes to Continuous Glucose Monitor medical device reimbursement options?
The proposed effective date has been moved from October 1 to November 1, 2025. Additional information about the effective date will be shared with providers in a bulletin.
How should Durable Medical Equipment (DME) billing be submitted when using bundled coding?
Guidance on using National Drug Codes (NDC) correctly will be provided as the implementation date approaches. In general, providers should submit Prior Authorization Requests (PAR) using the NDC number on the package of items being provided. Many CGM sensors come in bundled packages of three sensors, and this bundled package has its own NDC number that should be used.
Are Clinical Pharmacists eligible providers to bill for services related to reading Continuous Glucose Monitor (CGM) data? How does that process work?
Yes, pharmacists can bill for interpreting a CGM report using the 95251 Current Procedural Terminology (CPT) code. Pharmacist services still must be billed through the medical benefit.
Can prior authorization approvals be transferred between providers under the pharmacy benefit?
Prior authorization approvals under the pharmacy benefit are specific to the member. It will not be necessary to obtain a new prior authorization approval due to the member switching providers.
Will prior authorizations for Continuous Glucose Monitors (CGM) be valid for 6 months or 12 months?
Current coverage policy is that CGM Prior Authorization Requests (PAR) are valid for 6 months. At this time the Department does not intend to change this policy.
Will a change of provider form be required if a member switches between Durable Medical Equipment (DME) and pharmacy billing for their Continuous Glucose Monitor (CGM)?
No, a change of provider form will not be required.
Will a change of provider form be required if a member moves to a new pharmacy?
No, a change of provider form will not be required.
What does the process look like if a member wants to change their Continuous Glucose Monitor (CGM) within a benefit year?
The member and their healthcare provider will work together to decide what is best for the member. A new Prior Authorization, or a change of an existing one, may be required.
Will members be required to obtain a Continuous Glucose Monitor (CGM) receiver along with the CGM sensors?
Members are not required to obtain a Continuous Glucose Monitor (CGM) receiver along with the sensors.
How will members on Managed Care Plans access Continuous Glucose Monitors through Durable Medical Equipment (DME) and pharmacy? How will members be notified of these changes?
Effective November 1, 2025, all CGM devices for all age groups will be carved-out from the two Health First Colorado managed care plans (Denver Health and Rocky Mountain Health Plans Prime) and will be covered as wraparound benefits that are billed fee-for-service. This includes CGMs provided through either the medical Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) or the Pharmacy Benefit Manager (PBM) method.
Will HCPF consider adding a point of service lookback for the pharmacy CGM benefit to reduce administrative burden in prior authorizations?
HCPF may consider a point of service lookback for this benefit in the future. Due to the complexity of the system change this would require, a point of service lookback will not be included in the initial implementation of the pharmacy CGM benefit.
Will HCPF consider automatic approval processes for Continuous Glucose Monitors for example, in alignment with a concurrent insulin prescription?
HCPF may consider an automatic prior authorization approval process for this benefit in the future. Due to the complexity of the system change this would require, this will not be included in the initial implementation of the pharmacy CGM benefit.
Where can stakeholders reach out to request coverage of additional equipment and medications for Health First Colorado members?
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) policy and coverage questions requests can be submitted to HCPF_DME@state.co.us.
For more information, contact HCPF_stakeholders@state.co.us.