who do Humana MA plans cover CGMs for
Provider Briefing: Continuous Glucose Monitoring (CGM)
Payer: Humana Medicare Advantage (MA)
Plan Year: 2026
Clinical Focus: Medical Necessity & Documentation Integrity
1. Code & Policy Identification
Humana Medicare Advantage plans strictly adhere to CMS Local Coverage Determination (LCD) L33822 and Policy Article A52464. Coverage is typically processed through the Pharmacy Benefit (preferred) or the Durable Medical Equipment (DME) benefit.
| Code Type | Code(s) | Description |
|---|---|---|
| HCPCS (Supplies) | K0553 | Supply allowance for therapeutic CGM (covers sensors/transmitters) |
| HCPCS (Device) | K0554 | Receiver (monitor) for use with therapeutic CGM |
| CPT (Professional) | 95249 | Patient-provided equipment (setup/training) |
| CPT (Professional) | 95250 | Physician-provided equipment (professional CGM, 72hr+) |
| CPT (Interpretation) | 95251 | Physician interpretation and report (once per 30 days) |
| Policy ID | LCD L33822 | Glucose Monitors (Standardized Medicare Criteria) |
2. Authorization Status
- Prior Authorization (PA): Required for the initial device and ongoing supplies.
- Audit Risk: High. Post-payment audits frequently target the "6-month face-to-face" requirement and the "insulin-treated" status.
- Pharmacy vs. DME: Humana strongly prefers CGM fulfillment via Contracted Pharmacies. Check the member’s specific formulary for "Preferred" brands (typically Dexcom or FreeStyle Libre).
3. The "Documentation Checklist"
To meet Medical Necessity for the 2026 plan year, the SOAP note must explicitly document the following three findings:
- The "6-Month Rule": Documentation of an in-person or Medicare-approved telehealth visit with the treating practitioner within 6 months prior to the CGM order to evaluate diabetes control.
- Glycemic Control Criteria: The patient must meet ONE of the following:
- Insulin-Treated: Patient is treated with insulin (any type/frequency).
- Problematic Hypoglycemia: Documentation of recurrent (>1) Level 2 events (glucose <54 mg/dL) despite treatment adjustments, OR one Level 3 event (glucose <54 mg/dL with altered mental/physical status requiring assistance).
- Competency Statement: A clear statement that the patient (or caregiver) has received training and has the cognitive/physical ability to use the device and adjust therapy based on the data.
4. Denial Red Flags
- The "Non-Insulin" Trap: For Type 2 patients not on insulin, a denial is automatic unless the note details "Problematic Hypoglycemia." Simply stating "poor control" or "high A1c" is insufficient.
- Missing "Training" Documentation: Auditors look for proof that the provider evaluated the patient's ability to use the CGM. If the note only mentions the prescription, the claim for the device may be recouped.
- Step Therapy (Pharmacy): Humana may require a "Trial and Failure" of a preferred brand (e.g., Libre 3) before approving a non-preferred brand (e.g., Dexcom G7) unless a clinical contraindication is documented.
5. Clinical Action Plan: "Audit-Proof" SmartPhrases
| Scenario | Recommended Documentation Phrase |
|---|---|
| Initial Order | "Patient seen today for diabetes evaluation. Patient is currently insulin-treated with [Dosage/Frequency]. I have determined the patient/caregiver has sufficient training and cognitive ability to utilize a therapeutic CGM to improve glycemic control." |
| Non-Insulin User | "Patient is not currently on insulin but has a history of problematic hypoglycemia, specifically [Date/Event] where glucose was <54 mg/dL. Despite adjustments to [Medication Name], Level 2 hypoglycemic events persist, necessitating CGM for safety." |
| Interpretation (95251) | "Reviewed 72+ hours of CGM data. Time in Range (TIR) is [X]%. Noted nocturnal hypoglycemia at [Time]. Plan: Adjust basal insulin by [X] units. Patient educated on data trends." |
Pro-Tip: Ensure the ICD-10 code (e.g., E11.9 or E11.65) is linked directly to the CGM supply code on the claim to avoid "mismatched diagnosis" denials.
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